RU2550278C1 - V.k. kalabanov's method for choosing manual therapeutic approach to neurological manifestations of herniated or protruded lumbar disks - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to manual therapy (MT) and is effective for treating the patients suffering aggravated and regressive herniated and protruded (prolapsed) lumbar disks. A lumbar blocking direction is examined, and a MT approach based on the free motion is preferred. A neurologic examination aims at detecting extravertebral syndromes (EVS) anatomically associated with the lumbar (LP), sacral (SP) or both plexuses; muscular fixation of the lower extremities (LE) and the sanogenesis-related muscular fixation in the involved lumbar motor segments and the muscular fixation of thoracic (TS) and cervical (CS) spines are interrelated. If observing the EVS in both LEs, the MT techniques are applied to both LEs, whereas the EVS anatomically associated with the LP require the mobilisation technique to be used, which is post-activation traction (PAT), or the relaxation techniques representing the post-isometric relaxation (PIR), post-reciprocal relaxation (PRR) involving the CS and femoral flexors, adductors and rotators on the LE, and the TS and LS on the flexed spine and LE. The EVS anatomically associated with the SP is relieved by performing the PAT or PIR, the PRR on the CS, femoral flexors, adductors and rotators, foot extensors or flexors on the LE, and on the TS and LS on the flexed spine and LE. If observing the EVS anatomically associated with both the LP, and the SP, there are performed PAT or PIR, the PRR on the CS, femoral flexors and adductors, femoral flexors, adductors and rotators, foot extensors or flexors on the LE, and on the TS and LS in the neutral position of the spine and LE. The LE is first exposed at the level of muscular groups interrelated with more manifested, and then with less manifested EVS. The PAT or PIR, PRR on the CS is completed by manipulations from both sides, and on the LE by pressing myofascial trigger points of the LE and lumbus, on the pelvis by the mobilisation and manipulations on the sacroiliac joints, on the TS by the manipulations, and on the LS by the skin mobilisation. The procedure is completed by performing the manipulations on the intact lumbar motor segments from both sides. The lumbar manipulations are performed if observing no herniated disk sequestration, with a hernia localised no more than 1 cm deep.EFFECT: method provides choosing the MT approach more accurately and objectively depending on the EVS anatomically associated with the LP, SP with maintaining the sanogenesis-related muscular fixation of the lumbar motor segments, improving the venous blood and lymph outflow from the LE and spine by activating a muscular-venous pump of the LE and a dural-muscular-venous-lymphatic pump of the spine, preventing the hernia enlargement and sequestration, and reducing the length of treatment.20 dwg, 3 ex

Description

The invention relates to medicine, namely to manual therapy (MT), and is used to treat patients with hernias and protrusions (prolapses) of intervertebral discs (MTD) of the lumbar spine (POP) in the stage of exacerbation and regression of the disease.

Neurological manifestations of POP osteochondrosis are one of the main causes of temporary disability in people of the most socially active age. Currently, MT is one of the most effective conservative methods for treating patients with osteochondrosis. MT is based on the theory of reflex myofixation of the spine, limbs and blocking of the vertebral-motor segments (PDS), which are eliminated using special techniques (mobilization, relaxation, traction and manipulation) (see Veselovsky V.P. Practical vertebro-neurology and manual therapy. - Riga, 1991 .-- S.5-32, 249-341). MT is also used to treat neurological manifestations of hernias and protrusions (prolapses) of the MPD POP (see Sitel AB Manual therapy. - M .: Publishing center, 1998. - P.178-202). For one group of patients, the use of MT is an effective conservative method of treatment that avoids neurosurgical surgery for hernia MPD POP. In another group, the use of MT techniques is ineffective and can even cause complications in the form of an increase in the size of the hernia or its sequestration. In solving the problem of choosing MT tactics in the treatment of neurological manifestations of hernias and protrusions, MPD POP has no established views, and various authors have proposed their own approaches to its solution.

I. Methods, the choice of treatment tactics in which is based on the morphological principle:

1) G.D. Maitland, when choosing MT tactics, suggests using the damage level in EPP as a criterion. POP rotation in the direction of extension (extension) is used to mobilize the middle or upper lumbar region, rotation in the direction of flexion (flexion) is used for lower lumbar joints (see Maitland GD Manipulations on the spine. - M .: IPO POLIGRAN, 1992 . - P.88).

The disadvantage of this method is that the method is designed for use in patients with damage to the MTD at the same level of POP. Currently, for the diagnosis of hernias and protrusions of the MTD POP, magnetic resonance imaging (MRI) and X-ray computed tomography (CT) of the lumbosacral spine are widely used, in which one hernia and protrusion can be simultaneously detected in one patient both in the lower lumbar and and in the mid-lumbar and upper lumbar spine. If the patient determines the multilevel damage to the MPD POP, then the application of the known method becomes difficult. Another disadvantage of this method is that when choosing the direction of medical manipulation for EPP, the neurological manifestations of hernias and MTD protrusions in the lower limb (extravertebral syndromes) and their relationship with neurological manifestations in EPP, as well as other parts of the spine (vertebral syndrome) are not taken into account.

2) A.B. Sitel offers a choice of tactics for MT discogenic disease depending on the spatial location of the hernias of the MTD in the EPP (see Sitel AB Manual therapy. - M .: Publishing center, 1998. - P.183-190, 197).

In the treatment of the clinical manifestations of median hernias of the MTD POP with therapeutic movements, the author of the method considers flexion manipulations with distraction in the affected segment. In the treatment of the clinical manifestations of lateral hernias of MTD POP with therapeutic movements, the author of the method considers manipulation of extension in the affected segment with simultaneous bending towards scoliosis and distraction (see Sitel AB Manual therapy. - M .: Publishing center, 1998. - P.197 , 276).

The disadvantage of this method is that if a patient on an MRI or CT scan determines a multilevel damage to the MPD POP, in which there is a lateral hernia in one PDS and a median hernia in the other (or others), or circular (diffuse) protrusions are determined on several levels, the application of this method becomes difficult. The known method also does not take into account the neurological manifestations of hernias and protrusions of the MTD in the lower limb (extravertebral syndromes) and their relationship with neurological manifestations in POP, as well as other parts of the spine (vertebral syndrome). For example, a lateral hernia at the LI-LIV PDS levels irritates or compresses the roots involved in the formation of the lumbar plexus. In this case, extravertebral and vertebral syndromes involving flexor muscles develop. The use of extension manipulations is unjustified here, since this leads to a violation of sanogenizing myofixation, increased pressure in the herniated disc and the development of complications in the form of further prolapse of the hernial nucleus pulposus.

II. Methods, the choice of treatment tactics in which is based on the clinical principle (depending on the direction of blocking in PDS POP):

1) K. Levit offers a way to choose MT tactics depending on the direction of blocking in the intervertebral joints of the PDS POP. When treating light blocking of the II degree, it is necessary to determine which of the two intervertebral joints of the PDS POP is blocked (right or left), and, depending on the direction of its blocking, perform MT technical actions (relaxation, mobilization and manipulation) aimed at eliminating the blockade. If the patient has a blockade in the direction of flexion, then the techniques are carried out in flexion. And, accordingly, if the blockade is in the direction of extension, then the techniques are performed in extension. At the same time, K. Levit clarifies that this tactic is suitable if we are only talking about problems associated with disorders in the intervertebral joints. If the hernia of the MID POP and (or) radicular syndrome is the basis of the pain syndrome, then this approach does not work (see Levit K., Zahse J., Yanda V. Manual medicine: Translated from German.- M .: Medicine, 1993 - S.225-230). That is, with a pronounced blockade of grade I according to A. Stoddart, which occurs at the stage of exacerbation of hernias and protrusions of the MID POP, the method cannot be applied. In addition, with radicular syndrome, pain and other neurological manifestations are localized in the lower limb. Therefore, if the patient has neurological manifestations in the lower limb (extravertebral syndromes), this method also cannot be applied.

For the prototype of the present invention, a well-known method of choosing MT tactics in the treatment of neurological manifestations of hernias and protrusions of MTD POP is chosen, including determining the direction of blocking in EPP and choosing MT tactics in the direction of free movement in EPP (see Maigne R. Les Manipulations Vertébrales. Ed 3, Paris , Expansion Scientifique Francaise, 1960, vol 1; Maigne R. The Concept of Painlessness and Opposite Motion in Spinal Manipulations. American Journal of Physical Medicine 1964; 44: 55-69).

Robert Men proposed a method for choosing MT tactics depending on the direction of blocking in the intervertebral joints of the PDS POP, which he called the "rule of painlessness and the opposite movement." Its essence lies in the fact that you can never strengthen the movement in the joint, which causes or intensifies the pain, but on the contrary, it is important that the free movement is the opposite of all blocked ones. To do this, study the movement of the patient’s body while standing: in flexion and extension, tilts to the right and left, rotation to the right and left. This allows you to choose half of the lower back without pain (for example, the left). If the patient has free and painless movement in the direction of flexion, then on the intervertebral joints of the left half of the POP, manipulation is performed in flexion (Fig. 1). And, accordingly, if there is free and painless movement in the direction of extension, then on the intervertebral joints of the half of the lower back without pain manifestations (let's say right), the manipulation is performed in extension (figure 2). If the directions of free and painless movement are not detected, then manipulation on the POP is not performed (figure 3).

According to the author, the prototype method has the following advantages. The method can be applied in case of multilevel herniation damage by MPD POP (upper, middle and lower lumbar levels) with different directions (lateral, medial), since the method is not based on the level of damage in POP, but the direction of blocking movements in POP. That is, the method is based not on morphological, but clinical manifestations in POP. In the known method, reception is carried out in the direction of free movement, the opposite of all blocked. According to the author-applicant, this allows preserving the sanogenizing myofixation, which eliminates the instability in the PDS of POP with hernia, prevents the increase in pressure in the hernial disc and prevents the development of complications. If MT techniques are performed in the blocking direction (against the sanogenizing myofixation), this will lead to an exacerbation of the neurological manifestations of hernias and protrusions of the MPD POP.

However, the prototype method has the following disadvantages.

The first disadvantage of the prototype method is that when choosing MT tactics, it focuses only on the blocking direction in POP. According to the author-applicant, this method is more suitable for choosing treatment tactics in patients with vertebral syndrome in POP with a clear direction of blocking.

Vertebral syndrome includes such clinical symptoms as pain in the POP, reflex tension of the paravertebral muscles, block of movements in flexion and / or extension, a change in the shape of lumbar lordosis in the sagittal plane (smoothing of lumbar lordosis, sometimes the development of kyphosis, hyperlordosis), antalgic scoliosis in the frontal plane, Gar's pain points (pain on palpation of the spinous processes of the LIV, LV, SI vertebrae and paravertebral points at the same level), (see Veselovsky VP Practical vertebro-neurology and manual A therapy. - Riga, 1991. - P. 42-47, 54-60). Such patients are given a clinical diagnosis: lumbago or lumbalgia.

However, in addition to vertebral, extravertebral syndromes also exist.

Extravertebral syndromes include clinical symptoms such as: pain in the lower extremities; reflex tension of the muscles of the lower extremities with positive symptoms of tension (muscle-tonic manifestations); muscle weakness of the flexors, extensors of the foot and first finger, thigh (motor disorders in the innervation zone of one or two, less often three roots), zones of hypesthesia, anesthesia or hyperesthesia on the foot, lower leg and thigh (sensitive disorders in the innervation zone of one or two, less than three roots); loss, reduction or revitalization of the knee and Achilles reflexes; hypotrophy of the muscles of the lower extremities; foci of neurodystrophy (myofascial trigger points) in the muscles of the lower extremities; Balle pain points along the sciatic nerve and its branches, detected by palpation: above the foramen ischiadicum majus (between tuber ischii and trochanter major - the site of exit of the sciatic nerve from the pelvic cavity), in the gluteal fold, in the middle of the popliteal fossa (n.tibialis), posterior to capitulum fibulae (n. peroneus), behind the inner ankle, inward from the inner edge of the middle third of the sole (n. plantaris medialis - from n. tibialis) (see Veselovsky VP Practical vertebral neurology and manual therapy. - Riga, 1991 . - S.60-111). These patients are diagnosed with discogenic lumbar ischialgia or sciatica, discogenic radiculopathy or radiculoischemia (L1-3, L4, L5, S1 roots) - (diagnoses are abridged).

None of the known methods for choosing MT tactics takes into account the presence of extravertebral syndromes. When choosing MT tactics in patients with localization of neurological manifestations not only in the POP, but also in the lower limb, the prototype method also focuses on the direction of blocking in the intervertebral joints of the PPS POP and on the direction of the convexity of the analgesic scoliosis. According to the author of the prototype method, it is on the concave side of the analgesic scoliosis that there are directions of free and painless movement, and therefore this side is used for manipulations (FIG. 4, FIG. 5, FIG. 6, FIG. 7). That is, when choosing MT tactics in the presence of extravertebral syndromes, the author of the prototype method focuses on all the same clinical manifestations of vertebral syndrome in EPP.

It should be noted that not all patients with a combination of vertebral and extravertebral syndromes can detect a block of movements in POP in one direction (in flexion or extension). In the stage of exacerbation of the disease (with pronounced or severe pain syndromes) it happens that the patient can neither bend nor bend - the so-called "stake in the back." Also, at the stage of a regression of the disease (with mild or weak pain syndromes) it happens that patients can bend and unbend, but at the same time, there is pain in the EPP of the same severity in both flexion and extension. In addition, in the stage of disease regression, it happens that the movement of the patient’s body during tilts to the right and left, rotation to the right and left are painless, which makes it impossible to choose half of the lower back (right or left) without pain manifestations. But in the prototype method, it is the painless half of the lower back that is chosen for manipulation. That is, vertebral syndrome does not always provide information for choosing MT tactics.

The prototype method does not take into account neurological manifestations localized only in the lower limb. Patients get treatment for a chiropractor at different stages of the course of discogenic lumbar ischialgia and discogenic lumbosacral radiculopathy. In the stage of exacerbation of the disease, pain from POP migrates to the lower extremity, and patients have both vertebral and extravertebral syndromes. In the stage of disease regression, vertebral syndrome also undergoes regression. But patients still have pain and neurological manifestations localized in the lower limb, which are part of extravertebral syndromes and are the main ones at the time of treatment.

In addition, there are patients with discogenic sciatica and discogenic lumbosacral radiculopathy, in which, at the stage of an exacerbation of the disease, pain and other neurological manifestations are immediately localized in the proximal or distal parts of the lower limb (see Sitel A.B. Manual therapy. - M .: Publishing Center, 1998. - P.168). That is, the vertebral syndrome is not clinically expressed, but there are neurological manifestations that are part of extravertebral syndromes and are the main ones at the time of treatment.

Practice shows that in most patients with neurological manifestations of hernias and protrusions, MPD POP, vertebral syndrome cannot be taken as the basis for choosing MT tactics, and it is extravertebral syndromes localized in the lower extremities that play the main role:

1) with a combination of extravertebral syndromes with vertebral syndrome;

2) in the presence of extravertebral syndromes and regression of vertebral syndrome;

3) in the presence of extravertebral syndromes and clinically not pronounced vertebral syndrome.

Treatment of the neurological manifestations of hernias and protrusions of the MPD POP in the lower extremities and POP, as well as other parts of the spine, should occur according to one plan, which has a logical explanation.

The second disadvantage of the prototype method is that when choosing MT tactics, the relationship between extravertebral and vertebral syndromes is not taken into account.

An important component of extravertebral syndromes is myofixation of the lower extremities, which has a certain direction (flexion, extensor or neutral).

An important component of the vertebral syndrome is the sanogenizing myofixation in PDS POP with hernias and protrusions, which also has a certain direction (flexion, extensor or neutral). Sanogenizing (healing) myofixation limits the movement of the spine in a dangerous direction and thereby protects the unstable damaged PDS from complications in the form of further prolapse of the hernial nucleus pulposus, an increase in the inflammatory response and vascular disorders in the area around the hernia, which leads to an exacerbation of neurological manifestations of hernias and protrusions of the MPD .

According to the observations of the applicant, the direction of myofixation of the lower extremities is interconnected with the direction of the sanitizing myofixation of the damaged (damaged) PDS POP.

In the stage of exacerbation of the neurological manifestations of hernias and protrusions of the MTD POP, the flexor muscles of the lower extremities and flexors of the POP or extensor muscles of the lower extremities and extensors of the POP act as synergists. The neurological symptom of Vassserman is well known - extension in the hip joint of a straightened lower limb in a patient lying on his stomach causes pain along the front surface of the thigh and in the inguinal region. Laseg’s symptom is also well known - flexion of the rectified lower extremity in the hip joint with lumbosacral radiculitis causes pain in the lower back and on the back of the thigh and lower leg (first phase of the symptom) (see Skoromets A. A. Topical diagnosis of diseases of the nervous system: Guide for Doctors. - L.: Medicine, 1989. - P.38). When examining Wasserman's symptom, tension occurs in the rectus femoris muscle (flexor muscle of the lower extremities), causing pain along the anterior surface of the thigh, and tension of the iliopsoas muscle (flexor muscles of the POP and thigh), causing pain in the inguinal region. When examining the Laseg symptom, tension of the ischiocrural muscles (extensor muscles of the lower extremities) occurs, causing pain along the posterior surface of the thigh and lower leg, and tension of the paravertebral extensor muscles of POP, which causes lower back pain. That is, there is a relationship between the lower limb and POP: tension of the flexor muscles of the lower extremities and flexors of the POP or extensor muscles of the lower extremities and the extensors of POP provokes radicular pain in the lower limb and POP. Therefore, identifying extravertebral syndromes, the doctor simultaneously receives information about the direction of myofixation in the lower extremity, as well as the direction of sanogenizing myofixation in PDS POP with hernias and protrusions. This information allows you to build a logical treatment plan while preserving the sanogenizing myofixation of PDS POP, which is the basis for effective treatment without complications.

The third disadvantage of the prototype method is that when choosing MT tactics, the relationship between the sanitizing myofixation of PDS POP with the myofixation of not only the lower extremities, but also with the myofixation of the thoracic spine (GOP) and cervical spine (SHOP) is not taken into account. The applicant author believes that in the presence of extravertebral syndromes, the musculoskeletal system should not be considered in parts, but in general: the spine and lower limb. The following facts speak in favor of this statement. It is known that in the stage of exacerbation of the disease, the patient develops myofixation of the musculoskeletal system due to reflex-tonic contraction of the paravertebral muscles and muscles of the lower extremities. In the process of recovery, myofixation undergoes evolution from generalized to widespread, limited to local. Generalized myofixation captures the entire spine, shoulder and pelvic girdles, almost all the muscles of the body are tense, the patient is “constrained” (see Veselovsky VP Practical vertebroneurology and manual therapy. - Riga, 1991. - P.5-32). Thus, in the stage of exacerbation of the disease, despite the fact that the herniated disc is in the POP, myofixation extends not only to the POP and lower limb, but also to the GOP and SOP. The neurological symptom of Neri is well known - pain in the lower back and in the area of the affected root during forced bending of the patient’s head (see Skoromets A. A. Topical diagnosis of diseases of the nervous system: a Guide for doctors. - L .: Medicine, 1989. - P.38) . This symptom is detected in the acute stage in patients with discogenic lumbar ischialgia and discogenic lumbosacral radiculopathy. That is, there is a relationship between SHOP, GOP and POP, as well as the lower limb: the tension of the paravertebral extensor muscles and the dural sac in the SHOP and the upper part of the GOP provokes radicular pain in the POP and lower limb. More demonstrative is the slump-sit test, which combines the elements of the symptoms of Laseg, Neri and is used to detect lumbosacral radiculopathy. The patient in a sitting position with his hands behind his back is asked to lean forward, bending his head and neck, and then unbend his sore leg in the knee joint. If there is pain in the lower back and in the innervation zone of the affected root in the lower limb, the test is considered positive (see Shahbandar L., Press J. Diagnosis and nonoperative management of lumbar disk herniation. J Oper Tech Sports Med 13: 114-121, 2005) ( Fig. 8). That is, the tension of the paravertebral extensor muscles and the dural sac in the SHOP (head and neck tilt forward) and GOP (torso forward), as well as the extensor muscles of the patient while sitting, causes radicular pain in the POP and lower limb.

These facts suggest that manual therapy methods during the session must be performed on the entire musculoskeletal system involved in the pathological process: on the lower limb, sacroiliac joint (CPS), POP, GOP and SHOP. In this case, the treatment of neurological manifestations on the lower limb and spine should occur according to a logically interconnected plan and is subject to one clinical idea - the preservation of the sanogenizing myofixation of PDS POP with hernias and protrusions.

The fourth disadvantage of the prototype method is that the "rule of painlessness and opposite movement" is applied to only one technical action of MT - manipulation, which is performed on the damaged part of the spine - POP. It is impossible to apply the prototype method with various MT techniques (post-activation stretching (PAR), post-isometric relaxation (PIR), post-reciprocal relaxation (PRR), manipulation, mobilization, pressure) and the entire musculoskeletal system (lower limbs, spine).

The fifth drawback is the lack of correlation between manual medicine on the one hand and neurology on the other. Most chiropractors in our country have the basic specialty of a neurologist. Before starting treatment, patients with hernias and protrusions of the lumbar intervertebral discs undergo a neurological examination, a neurological diagnosis is made, and medication is prescribed. The same patients undergo manual diagnostics and, based on its data, apply MT techniques on the spine and lower extremities. Thus, the chiropractor must make two diagnoses: the first is neurological, indicating the level of the lesion and the affected segment, the course and stage of the disease, the severity of the pain syndrome and the degree of violation of neurological functions, and the second is the manual, noting the type, nature, localization, direction of movement disorders systems, the severity of the limitation of mobility and displacement of bones, the degree of pain of passive movements, the degree of weakening and shortening of muscles (Gubenko V.P. Manual therapy in a vertebral neurologist and:. Manual - K .: Medicine, 2006. - p.181).

It turns out that in real life, neurology and manual therapy live, as it were, separately from each other. The applicant author believes that in the presence of extravertebral syndromes manual diagnosis and determination of the direction of free movement, the opposite of all blocked in POP, can not be carried out. Practical activity shows that the identified neurological syndromes and the neurological diagnosis of the patient are at the same time a guide for choosing the tactics of using MT techniques on the lower limbs and spine.

According to the classification of I.P. Antonova (1984), when formulating the diagnosis, the leading neurological syndrome should be put in first place, since it is he who decisively determines the specifics of the patient's condition. However, given that the coding in accordance with ICD-10 follows the primary disease, a different diagnosis sequence is allowed, in which vertebral pathology is indicated first (disc herniation, spondylosis, spondylolisthesis, spinal stenosis, etc.), and then neurological syndrome (see. Handbook for the formulation of a clinical diagnosis of diseases of the nervous system. / Edited by VN Shtok, OS Levin. - M .: Medical Information Agency LLC, 2010. - P. 405).

With any formulation of the diagnosis, it still reflects the leading extravertebral neurological syndrome, which is the key to choosing MT tactics in the treatment of neurological manifestations of hernias and protrusions of the MPD POP. Extravertebral neurological syndrome gives the doctor information about the direction of myofixation in the lower limb, as well as the direction of sanogenizing myofixation in the damaged (damaged) PDS POP, as well as the direction of myofixation in the GOP and SOP: flexion, extensor or neutral. This information allows you to build a logical treatment plan while preserving the sanogenizing myofixation of PDS POP.

From the foregoing, we can conclude that the known method of choosing tactics of MT is insufficiently effective.

The objective of the invention is:

- increasing the effectiveness of treatment by maintaining the sanogenizing myofixation of PDS POP with hernias and protrusions;

- improving the accuracy and objectivity of the choice of MT tactics, taking into account the presence and options of extravertebral syndromes anatomically associated with the lumbar, sacral, or both of these plexuses;

- improving the outflow of venous blood and lymph from the lower extremities and the spine due to the activation of the muscular-venous pump of the lower limb and the dural-muscular-venous-lymphatic pump of the spine;

- reduction of complications in the form of an increase in the size of the hernia or its sequestration and their prevention;

- reduction of treatment time.

The problem is solved in that in the known method of choosing MT tactics in the treatment of neurological manifestations of hernias and protrusions of the lumbar intervertebral discs, including studying the direction of blocking in the lumbar spine, and choosing MT tactics in the direction of free movement in the lumbar spine, a neurological examination of the patient is carried out and determined extravertebral syndromes, anatomically associated with the lumbar, sacral, or both of these plexuses, determine the relationship of the direction of myo fixation of the lower extremities with the direction of sanogenizing myofixation in the damaged vertebral-motor segments of the lumbar spine, as well as with the direction of myofixation of the thoracic and cervical spine, then perform MT techniques, choosing the position of the spine and lower extremities from: flexion, extensor, neutral depending on extravertebral syndrome anatomically associated with the lumbar and / or sacral plexus, and in the presence of extravertebral syndromes in both lower X extremities, MT techniques are performed on both lower extremities, and in extravertebral syndromes anatomically associated with the lumbar plexus, mobilization techniques - post-activation stretching (PAR) or relaxation techniques - post-isometric relaxation (PIR), post-reciprocal relaxation (PRR) on the cervical spine, the lower extremity of the muscles that bend, bring and rotate the outside of the thigh, and on the thoracic and lumbar spine, perform in the flexion position of the spine and lower extremities, with extravertebral syndromes anatomically associated with the sacral plexus, mobilization technique PAR or relaxation techniques PIR, PRR on the cervical spine, on the lower extremity of the muscles that extend, extend and rotate the outside of the thigh, muscles that extend and bend the foot, and on the thoracic and lumbar spine perform in the extensor position of the spine and lower extremities, with extravertebral syndromes, anatomically associated with both the lumbar and sacral plexuses, mobilization technique AR or relaxation techniques PIR, PRR on the cervical spine, on the lower extremity of the muscles that bend and adduce the thigh, the muscles that extend, divert and rotate the outside of the thigh, the muscles that extend and bend the foot, and on the thoracic and lumbar spine the spine and lower extremities, while the effect on the lower limb is first performed on muscle groups, interconnected with less and then with more pronounced extravertebral syndromes, the effect of the mobilization technique P P or relaxation techniques PIR, PRR on the cervical spine are completed by manipulations on both sides, on the lower extremity by pressing myofascial trigger points of the lower limb and lower back, on the pelvis by mobilization or manipulations on the sacroiliac joints, on the thoracic spine by manipulations, on the lumbar spine skin mobilization, at the end of the course of treatment, as the final dose, perform manipulations on healthy vertebral-motor segments of the lumbar spine with about on both sides, moreover, manipulations on the lumbar spine are performed provided that hernias of the lumbar intervertebral discs are without sequestration, and their size is no more than 1 cm in depth.

The method is illustrated in graphic material.

In FIG. 1, 2, 3, 5, 7 gives a diagram of the limitations of the prototype method. The number of lines crossed out indicates the severity of the restrictions. In FIG. 1, 2, 3, 5, 7 are indicated:

F - bending,

E - extension,

FR - right lateral bending,

FL - left side bending,

RR - rotation to the right,

RL - rotation to the left.

In FIG. 4 shows a patient with convex scoliosis in the direction of sciatica (prototype method).

In FIG. 6 shows a patient with concave scoliosis in the direction of sciatica (prototype method).

In FIG. 8 depicts a neurological test, "sitting lean."

In FIG. Figures 9-20 show tomograms before and after the treatment to examples of specific performance with the choice of MT tactics according to the proposed method.

The proposed method meets the criterion of "novelty", since in the process of patent information research, no sources were found discrediting the novelty of the invention.

The present invention meets the criterion of "inventive step", since the search process did not reveal technical solutions with essential features of the proposed method.

Currently, the following data are known from sources of scientific literature, which make it possible to substantiate the proposed choice of MT tactics.

1. An important role in the formation of vertebral and extravertebral syndromes is played by myofixation of the musculoskeletal system. Myofixation occurs due to reflex-tonic contraction of paravertebral muscles and muscles of the lower extremities. It is necessary to ensure immobility in an unstable (unstable) PDS with hernia, protrusion (prolapse) for the period of recovery. Generalized myofixation captures the entire spine, shoulder and pelvic girdles, almost all the muscles of the body are tense, the patient is “constrained”. Common myofixation is upper (cervicothoracic) and lower (lumbar-thoracic). It is characterized by the spread of the tonic contraction of the paravertebral muscles to the muscles involved in the functioning of large proximal joints (shoulder, hip). Limited myofixation creates fixation only of the vertebral-motor segments, it also happens to be upper (cervicothoracic) and lower (lumbar-thoracic). Local myofixation is characterized by muscular-tonic reactions of segmental muscles of damaged PDS. In the process of recovery, myofixation undergoes evolution from generalized to widespread, limited to local. As a rule, upon reaching local myofixation, clinical manifestations subside. The movement from illness to recovery is the movement from generalized myofixation to local myofixation. Gradually, fibrosis and ossification develops in the damaged MTD, arthrosis forms in the intervertebral joints, spondylosis in the ligamentous apparatus, and the functional blockade of the damaged PDS goes into organic. At the same time, the patient recovers (see Veselovsky V.P. Practical vertebral neurology and manual therapy. - Riga, 1991. - P.5-32; Sitel A.B. Manual therapy. - M.: Publishing Center, 1998. - C. 201).

2. Also in vertebral neurology and MT there is the concept of sanogenizing myofixation of damaged PDS.

Sanogenizing (healing) myofixation is a contraction of segmental muscles that fixes unstable PDS with a hernia, suppresses irritation of the receptors of the synuvertebral nerve and eliminates pain (see Veselovsky V.P. Practical vertebroneurology and manual therapy. - Riga, 1991. - P.18, 45).

3. Known anatomical patterns of innervation of the muscles of the lower extremities. From the lumbar plexus (Th12, L1-L4), nerves emerge that innervate the muscles that bend and lead the thigh, as well as rotate the thigh outward. From the sacral plexus (L4-L5, S1-S4), nerves emerge that innervate the muscles that extend, extend, and rotate the thigh outwards (see Human Anatomy. In 2 volumes. T.2 / Aut.: E.I. Borzyak , V.Ya. Bocharov, L.I. Volkova, et al .: / Under the editorship of M.R. Sapin. - M .: Medicine, 1987. - S.411-419).

4. Radicular, muscle and neurovascular extra-cerebral syndromes are also known that are anatomically associated with the lumbar, sacral, or both the lumbar and sacral plexuses. Muscular syndromes are divided into muscle-tonic and neurodystrophic (see Veselovsky VP Practical vertebro-neurology and manual therapy. - Riga, 1991. - P.78-111). In practical life, any of the forms presented here rarely appears in isolation (see Popelyansky, Y. Orthopedic Neurology. Vertebroneurology. Manual for Doctors. Volume 1. Syndromology. - Kazan, 1997. - P.549). The structure of radicular syndromes also includes muscle-tonic manifestations. For MT tasks, it is more convenient to use radicular, muscle-tonic and neurodystrophic syndromes. This is due to the fact that at the stage of exacerbation and regression of the disease, these syndromes are well expressed and therefore easily detected.

Neurovascular extravertebral syndromes have, as a rule, not sharply pronounced vertebral syndrome and weakly expressed muscle-tonic and neurodystrophic manifestations in the lower extremity (see Veselovsky VP Practical vertebroneurology and manual therapy. - Riga, 1991. - P.105-106 )

5. The question arises: is it possible to correct the hernia of the MTD POP using MT techniques?

According to foreign and domestic scientific data, the reduction of MTD hernia during the MT procedure does not occur (see Fischenko V.Ya., Martynenko G.F., Shargorodsky BC, Shvets V.A. Conservative treatment of osteochondrosis of the spine. Kiev: Health, 1989. - P.26-27; Vasilieva LF Manual diagnostics and therapy, clinical biomechanics and pathobiomechanics. A manual for doctors. - St. Petersburg: Publishing House "Foliant", 2001. - P.23).

The author-applicant explains the lack of reduction of hernia (protrusion, prolapse) of the MTD by the fact that hernial gates, consisting of torn fibers of the fibrous ring and hyaline plates of adjacent vertebrae, remain open. The posterior longitudinal ligament keeps the hernial contents from further loss. It is known that in abdominal surgery, in addition to setting into the abdominal cavity of the hernia itself, the hernia gate is always closed with the help of operative plastic surgery, which is a guarantee against relapse. It is impossible to close the hernia gate with manual therapy methods (see V.K. Kalabanov. Regression of sequestration and large hernias of the lumbar intervertebral discs as a result of complex treatment using the author's method of manual therapy. // Manual therapy. 2009; No. 1 (33). - S.8-22).

It is also known that clinical recovery occurs when fibrosis, ossification occurs in the damaged disk, and as a result, the immobility of adjacent vertebrae in the damaged PDS (see Fischenko V.Ya., Martynenko G.F., Shargorodsky BC, Shvets V.A. Conservative treatment of osteochondrosis of the spine. - Kiev: Health, 1989. - S.20-21). In neurology, this condition is indicated by the term “spinal fusion”, in manual therapy - “organic blockade”, and in the classification of A. Stoddart blockade - “blockade 0 degree”: no movement, ankylosis of the joint (see Ivanichev G.A. Manual medicine. - M .: LLC "MEDpress", 1998. - P.66).

6. At the same time, scientific evidence has accumulated that sequestration and hernias of MPD POP can significantly decrease in size, or completely disappear after conservative treatment. The scientific literature describes cases of spontaneous regression of sequestration and hernias of MTD, which occurred in the period from 3 to 12 months, which was established using x-ray computed tomography (CT) and magnetic resonance imaging (MRI). In particular, cases of the complete disappearance of sequestration of hernias of MTD for 3 months are described. Various theories have been proposed to explain the mechanism of this regression, such as the theory of disk dehydration, the theory of reduction of the precipitated part of the disk and the resorption of the disk by phagocytes. The most evidence-based is the resorptive theory, where the authors, using histological and histochemical studies, showed inflammatory changes mainly in the gelatinous nucleus and, to a lesser extent, in the fibrous ring of operatively removed sequestration and hernias of MPD POP. These changes are represented by cell macrophage infiltration and a small amount of T-lymphocytes, neovascularization and granulation (see Ikeda T., Nakamura T., Kikuchi T. et al. Pathomechanism of spontaneous regression of the herniated lumbar disc: hystologic and immunohistochemical study. // J. Spinal Disord. 1996. Vol. 9 No. 2. P. 136-140).

A number of foreign authors have chosen such a factor as neovascularization as a prognostic criterion for the resorption process. An MRI study with iv administration of gadolinium-based contrast agents revealed that around the sequestration and hernias of the MTD, which subsequently underwent spontaneous resorption, a contrast rim appears - a neovascularization zone. The thicker the contrast rim, and, accordingly, the neovascularization is more active, the process of resorption of the hernial gelatinous nucleus was further significant. The presence of a contrasting rim was a criterion for selecting patients to continue conservative treatment (see Autio RA, Karpinnen J., Ninimaki J. et al. Determinants of spontaneous resorption of intervertebral disc herniation. // J. Spine. 2006. Vol.31, No. 11 P.1247-1252). During a morphological study of autopsy herniated discs, vessels of the lymphatic (mainly), venous and arterial types are found in the peripheral sections of the fibrous ring (see Magomedov MK, Golovatenko-Abramov KV Dynamics of structural changes in herniated discs in and ex vivo based on a comparison of morphology and magnetic resonance imaging. // Manual therapy. 20003, No. 3 (11). - P.23-31).

However, in the process of developing the proposed method, the applicant applicant found theoretical premises and explanations, which later became one of the essential features.

1. The applicant author expands the concept of sanogenizing myofixation and includes, in addition to the static component of contraction of segmental muscles and fixation of unstable PDS with hernia, also a dynamic component - a protective restriction of the movement of the spine in a dangerous direction (in flexion or (and) in extension). The applicant author believes that the sanogenizing myofixation also has a certain direction: flexion, extensor and neutral. Performing MT techniques against the direction of sanogenizing myofixation in an unstable PDS with a hernia (for flexion or extension) is dangerous and can lead to complications. This is due to the fact that the fibrous ring is torn in the hernial disc, and the hernial contents, consisting mainly of a gelatinous nucleus, are prevented from further loss to the spinal canal only by the remnants of the fibrous ring and (or) the posterior longitudinal ligament. If MT methods are performed against muscle traction, this leads to a displacement of the overlying vertebra in an unstable PDS with a hernia, an increase in pressure in the hernial disc and a final rupture of the fibrous ring and (or) the posterior longitudinal ligament. In this case, the gelatinous nucleus is extruded into the lumen of the spinal canal and, accordingly, an increase in the size of the hernia or its sequestration. Preservation of sanogenizing myofixation during MT treatment, on the contrary, eliminates the instability in the damaged POP PDS, does not allow an increase in pressure in the herniated disc during the administration, and, as a result, avoids complications.

2. The author-applicant highlighted the formation of three clinically important variants of lower limb myofixation that occur with extravertebral syndromes that are suitable for MT tasks:

a) anatomically associated with the lumbar plexus - due to the tension of the muscles that bend and bring the thigh, as well as to a lesser extent, rotate the thigh outward;

b) anatomically associated with the sacral plexus - due to the tension of the muscles that extend, extend, and rotate the thigh outwards. This option is most common;

c) anatomically associated with both the lumbar and sacral plexuses. This option is much less common than the first two and is observed in patients with clinically significant hernias of the MTD at several levels of EPP or sequestered hernia of the MTD at the same level of EPP.

3. The applicant author believes that myofixation of the lower extremities with extravertebral syndromes has a certain direction: flexion, extensor and neutral.

a) The flexion direction of myofixation of the lower extremities - anatomically associated with the lumbar plexus. With compression or reflex damage to the roots of the femoral nerve (L1-L4), myofixation of the lower limb develops due to the hip flexor muscles innervated by it. Additionally, muscles innervated by the obturator nerve (L2-L4) are involved to a greater or lesser extent in the myofixation process. At the same time, myofixation of the lower limb develops due to the muscles of both the flexing thigh and the adductors, and to a lesser extent rotating the thigh outwards.

b) The extensor direction of myofixation of the lower extremities - anatomically associated with the sacral plexus. With compression or reflex damage to the sciatic nerve roots (L4-L5, S1-S3), myofixation of the lower limb develops due to the hip extensor muscles innervated by it. Additionally, muscles innervated by short branches of the sacral plexus (L4-L5, S1-S2) are involved to a greater or lesser extent in the myofixation process. At the same time, myofixation of the lower extremity develops both due to the muscles that extend the thigh, and the abductors, as well as the femurs that rotate outwards.

It is clear that in these variants of lower limb myofixation (a and b), the flexion or extensor direction of myofixation will prevail, since the main movements in the thigh are flexion and extension, and, accordingly, the flexor muscles and extensors of the thigh are the largest and strongest . The nerves that innervate the hip flexor muscles (femoral nerve) and the hip extensor muscles (sciatic nerve) are also the largest in the human body.

c) The neutral direction of myofixation of the lower extremities - anatomically associated with both the lumbar and sacral plexuses. This option is found in patients with clinically significant MTD hernias at several levels of EPP or a large sequestered hernia of MTD at the same level of EPP with compression or reflex damage to the roots of the femoral and sciatic nerves. At the same time, myofixation develops due to the muscles of both the bending and advancing thighs, and the extensors, abducting and outwardly turning the thigh - a half-bent position of the lower limb is formed.

4. The applicant author believes that myofixation of the spine in extravertebral syndromes also has a certain direction: flexion, extensor and neutral.

The hip flexor and extensor muscles are synergists of the muscles that flex and extend the POP, since with a fixed hip, the flexor and hip extensors themselves flex and extend the body. POP flexor and extensor muscles are synergists of the muscles that flex and extend the GOP and SOP. Therefore, revealing radicular and muscle extravertebral syndromes anatomically associated with the lumbar and (or) sacral plexuses, we simultaneously obtain information about both the direction of myofixation in the lower limb and the direction of sanogenizing myofixation in PDS POP, as well as the direction of myofixation in GOP and SHOP.

a) The flexion direction of myofixation of the spine - anatomically associated with the lumbar plexus. In extravertebral syndromes anatomically associated with the lumbar plexus, the patient forms flexion myofixation of the lower limb (due to muscle tension in the flexors, adductors, and femurs that rotate outwards). At the same time, the patient forms a flexion sanogenizing myofixation of PDS POP - bent position - (due to muscle tension of the flexing POP), as well as flexion myofixation of GOP and SHOP.

b) The extensor direction of myofixation of the spine - anatomically associated with the sacral plexus. With extravertebral syndromes anatomically associated with the sacral plexus, the patient develops extensor myofixation of the lower limb (due to the muscles of the extensor, abducting and outwardly rotating femur). At the same time, the patient forms extensor sanogenizing myofixation of PDS POP - an unbent position - (due to muscle tension of the extensor POP), as well as extensor myofixation of GOP and SHOP.

c) The neutral direction of spinal myofixation - anatomically associated with both the lumbar and sacral plexuses. In extravertebral syndromes anatomically associated with both the lumbar and sacral plexuses, the patient forms a neutral myofixation of the lower extremity - a half-bent position (due to muscles that flex and bring the thigh, as well as the extensor, abducting and outward-turning thigh). At the same time, the patient forms a neutral sanogenizing myofixation of PDS POP - a half-bent position (due to muscle tension in both flexing and extensing POP), as well as neutral myofixation of GOP and SHOP. This option is found in patients with clinically significant MTD hernias at several levels of POP or large sequestered hernia of MTD at the same level of POP.

Thus, the applicant author found a relationship between extravertebral syndromes and the direction of myofixation of the lower extremities, the direction of sanogenizing myofixation of PDS POP, as well as the direction of myofixation of GOP and SHOP.

5. Similarly to the muscle-venous pump of the lower extremities, the main function of which is to balance the increased flow of arterial blood to the leg structures (muscles, ligaments, bones, etc.) and the outflow of venous blood from them to the heart during movement (see Dumpe E. .P., Ukhov Yu.I., Shvalb P.G. Physiology and pathology of venous circulation of the lower extremities. - M .: Medicine, 1982. - P.59-68), the applicant applicant put forward a hypothesis about the presence of dural-muscular venous pump of the spine (see Kalabanov V.K. Dural-muscular-venous-lymphatic spinal pump Hypothesis or real fact? // Manual therapy. 2006; No. 4 (24). P. 42-48; Kalabanov VK Dural-muscular-venous-lymphatic pump of the spine. Message II. Experimental data of magnetic resonance tomography on the functional displacement of the dural sac in the epidural and spinal cord in subarachnoid spaces. // Manual therapy. 2007; No. 1 (25). - P.74-81; Kalabanov VK. Dural-muscular-venous-lymphatic pump of the spine. Message III. Experimental data of magnetic resonance imaging on the functional compression of the venous vessels of the epidural space by the dural sac. // Manual therapy. 2007; No. 2 (26). - S.12-19; Kalabanov V.K. Dural-muscular-venous-lymphatic pump of the spine. Message IV. The hypothesis of structural and functional organization. // Manual therapy. 2007; No. 3 (27). - S. 54-69).

When a person moves, there is an increased influx of arterial blood to the structures of the spinal column (muscles, ligaments, vertebrae, spinal cord, roots of the spinal nerves, etc.) and cerebrospinal fluid to the spinal cord. The outflow of blood, cerebrospinal fluid, tissue fluid from the structures of the spine is carried out mainly through the venous system, as well as through the lymphatic system and does not allow the development of edema of the structures of the spinal column. The movements of the dural sac in the spinal canal and the dynamic contractions of the paravertebral muscles outside the spine during the movements of the spinal column perform the function of a peripheral venous-lymphatic pump (pump), which pushes venous blood and lymph from the spinal column to the heart. In this case, there is a decrease in pressure in the venous and lymphatic systems of the spine.

The author-applicant conducted a series of experiments using MRI, where the techniques were performed PAR. It turned out that during movements with functional deformations (bends) of the spine, the dural sac is stretched and shifted to the concave side of the spinal canal. This causes alternating compression of the venous and lymphatic vessels from the concave side of the spinal canal and their compensatory expansion with a convex. At the same time, alternating dynamic contractions and relaxations of the paravertebral muscles occur outside the spine. This causes alternating compression of the venous and lymphatic vessels outside the spine.

Functional deformations (bends) of the spine occur during various movements of the human body (walking, running, turning, bending). The most common movement is, of course, walking, during which the spine takes the form of a spiral, twisting in one direction or the other.

The function of the dural-muscular-venous-lymphatic pump of the spine is to balance the increased flow of arterial blood to the structures of the spine (muscles, ligaments, vertebrae, spinal cord, roots of the spinal nerves, etc.), cerebrospinal fluid to the spinal cord and outflow of venous blood, lymph from them to the heart during movement with functional deformities of the spine.

In patients with hernia and protrusion of the disc in the acute period, the pump is disrupted. Hernia and inflammatory swelling of the tissues block the dural sac and cause constant compression of the venous and lymphatic vessels in the spinal canal at the lesion level. A persistent reflex spasm of the paravertebral muscles blocks the movement of the spinal column and also causes constant compression of the venous and lymphatic vessels outside the spine.

Violation of the regional outflow of venous blood from the lumbosacral segments and roots of the spinal cord, internal and external vertebral venous plexuses leads to venous stasis and edema of the roots of the spinal cord, and varicose veins of the internal vertebral plexuses. Venous pressure in the spinal canal and vertebrae increases 1.5-2 times (Ivanova T.A., Tikhodeev S.A., Skoromets A.A., Solonsky A.V. Venospondyloin infusion in the treatment of neurological manifestations of osteochondrosis of the lumbar spine. / / Vertebroneurology. 2002, No. 1-2 - S.51-58).

Therefore, one of the important factors contributing to the elimination of the neurological manifestations of hernias and protrusions of the MPD POP is the restoration of the impaired outflow of venous blood and lymph from the spinal column to the heart. The author-author believes that this is achieved by enhancing the work of the functional structure - the dural-muscular-venous-lymphatic pump of the spine.

The restoration of blood circulation and lymph outflow is also an important factor in the process of spontaneous resorption of hernia gelatinous nucleus by phagocytes. Phagocytes and T-lymphocytes enter the hernia through the vessels in the neovascularization zone, which absorb its tissue, the products of its decay are removed through the vessels and spontaneous resorption of the hernial nucleus pulposus occurs.

To restore the functioning of the spinal pump and, accordingly, the outflow of venous blood and lymph from the spinal canal and from the spinal column as a whole, it is necessary to eliminate muscle spasm and again “teach” the spinal column to perform movements with functional bends. This problem is solved by the author’s method of mobilization technology PAR. In the spinal canal, venous-lymphatic congestion is eliminated, pressure is reduced, edema of the tissues of the epidural tissue, hernia and spinal nerve root is eliminated, the flow of arterial blood is restored (Manual exposure method according to V. K. Kalabanov. Patent for the invention No. 2237459 from 10.10.04, ; A method for the complex treatment of neurological manifestations of hernias and protrusions of the lumbar intervertebral discs according to V. K. Kalabanov. Patent for the invention No. 2287317 dated November 20, 2006).

The proposed method allows to obtain the following positive effect.

I. The neurological principle of choosing MT tactics in the treatment of neurological manifestations of hernias and protrusions of the lumbar intervertebral discs.

The proposed method for choosing MT tactics in the treatment of neurological manifestations of hernias and protrusions of the MPD POP in patients with extravertebral syndromes is based on a neurological criterion. At the same time, a standard neurological examination is carried out, which includes: identifying a characteristic pattern of pain, identifying positive symptoms of lower extremity tension, checking strength, sensitivity, knee and achilles reflexes, identifying muscle hypotrophy, as well as foci of neurodystrophy and Ballé pain points in the lower extremities. A neurological examination reveals a leading extravertebral syndrome, which is recorded in a neurological diagnosis. Extravertebral syndrome reflects the name of either muscle groups or the root (roots) anatomically associated with the lumbar and / or sacral plexus. Therefore, you can immediately determine what direction the myofixation of the lower extremities is, the direction of sanogenizing myofixation in the damaged (damaged) PDS POP, as well as the direction of myofixation in GOP and SHOP: flexion, extensor or neutral. The sequence of actions can be represented as follows: neurological examination → identification of extravertebral syndrome → diagnosis → choice of MT tactics.

In this case, a logical unity of the neurological examination, the neurological diagnosis and the resulting MT tactics choice is achieved.

1. MT tactics in identifying extravertebral syndromes anatomically associated with the lumbar plexus.

This tactic option is suitable for patients who, during a neurological examination, radicular syndromes (radiculopathy of L1, L2, L3 or (and) L4 roots), radicular-vascular syndromes (radiculosemia of L1, L2, L3 or (and) L4 roots), muscle syndromes (iliopsoas muscle, quadriceps or adductors of the thigh).

Examples of formulating diagnoses:

1. Discogenic radiculopathy L3, L4 roots on the right, recurrent course, stage of exacerbation, severe pain.

2. Osteochondrosis of the lumbar spine. Left-sided disc herniation L3-L4, protrusion of the disc L2-L3. Discogenic, moderately expressed lumbalgia with muscular-tonic manifestations, ileo-lumbar muscle syndrome on the left.

With any formulation of the neurological diagnosis, it reflects the leading extravertebral neurological syndrome, which has an anatomical connection with the lumbar plexus, which allows you to choose the treatment tactics. In the first example of the diagnosis, this is radiculopathy of L3, L4 roots (radicular syndromes, which include muscular-tonic manifestations), and in the second example of the diagnosis, it is iliopsoas muscle syndrome (reflex muscle syndrome). In the second example of the diagnosis, extravertebral syndrome (iliopsoas muscle syndrome) plays a major role in the choice of treatment tactics, since, unlike lumbalgia, it indicates an anatomical relationship with the lumbar plexus. These patients have a flexion direction of myofixation of the lower limb and, accordingly, a flexion direction of sanogenizing myofixation in the damaged (damaged) PDS POP, as well as a flexion direction of myofixation of GOP and SHOP.

When identifying extravertebral syndromes anatomically associated with the lumbar plexus, in order to maintain flexion sanogenizing myofixation in the damaged (damaged) PDS POP, which limits its (their) extension, the applicant uses the following tactics:

a) the mobilization technique of PAR or relaxation techniques of PIR, PRR at the SHOP is performed in the flexion position of the spine and lower extremities;

b) SHOP manipulations are performed in the flexion position of the spine and lower extremities on both sides;

c) the mobilization technique of PAR or relaxation techniques of PIR, PRR on the lower extremity (the muscles of the flexor, adducting and rotating the thigh outwards) are performed in the flexion position of the spine and lower extremities;

d) the MPTP pressure on the lower limb and lower back is performed in the flexion position of the spine and lower extremities;

d) the mobilization technique of PA or relaxation techniques of PIR, PRR on the spine (GOP, POP) is performed in the flexion position of the spine and lower extremities;

f) mobilization and manipulation of the KPS is performed in the flexion position of the spine and lower extremities;

f) GOP manipulations are performed in the flexion position of the spine and lower extremities;

g) POP skin mobilization is performed in the flexion position of the spine and lower extremities;

h) manipulations on healthy PDS POP are performed in the flexion position of the spine and lower extremities on both sides at the end of the course of treatment, as a final reception;

i) OPP manipulations are performed provided that the MPD POP hernias are without sequestration and their size is not more than 1 cm in depth.

At the same time, the flexion position of the spine, in which the flexion sanogenizing myofixation of the PDS POP is maintained, during the implementation of the PAR technique, the author-applicant strengthens. For this, oculomotor synergies are used with participation in the flexion movement of the head, SHOP and GOP.

MT receptions are performed starting from the peripheral parts of the body (SHOP and lower limb) and ending in EPP.

2. MT tactics in identifying extravertebral syndromes anatomically associated with the sacral plexus.

This tactic option is suitable for patients in whom, during a neurological examination, radicular syndromes (radiculopathy of L5 or (and) S1 roots), radicular-vascular syndromes (radiculosemia of L5 or (and) S1 roots), muscle syndromes involving muscles of the lower back and back thigh muscles (lumbar ischialgia), posterior thigh muscles (sciatica), piriformis muscle (piriformis syndrome), middle and minor gluteus muscles (glutalgia), ileo-tibial tract, or calf muscle (crumpi).

Examples of formulating diagnoses:

1. Discogenic radiculoischemia of L5, S1 roots on the left, stable course, stage of regression, moderate pain, severe paresis and hypesthesia of the left foot.

2. Discogenic radiculopathy of L5 root on the right, with moderate pain, stage of exacerbation, stationary course.

3. Discogenic pronounced lumbar ischialgia on the left with muscular-tonic and neurodystrophic manifestations, stable course, stage of exacerbation.

4. Osteochondrosis of the lumbosacral spine. Right-sided disc herniation L5-S1, median disc herniation L4-L5. Discogenic radiculopathy S1 on the right, the stage of exacerbation, severe pain and secondary muscular-tonic manifestations, piriformis syndrome.

5. Osteochondrosis of the lumbosacral spine. Right-sided disc herniation L5-S1. Discogenic moderately expressed right-sided sciatica with muscle-tonic and neurovascular manifestations, stage of regression.

In all examples of diagnoses, extravertebral syndromes (sciatica, lumbar ischialgia, radiculopathy, or radiculoischemia L5 or (and) S1 roots) play a major role in choosing MT tactics, since they indicate an anatomical connection with the sacral plexus. These patients have an extensor direction of myofixation of the lower limb and, accordingly, an extensor direction of sanogenizing myofixation in the damaged (damaged) PDS POP, as well as the extensor direction of myofixation of GOP and SHOP.

When identifying extravertebral syndromes anatomically associated with the sacral plexus, in order to maintain extensor sanogenizing myofixation in the damaged (damaged) PDS POP, which limits its (their) flexion, the applicant uses the following tactics:

a) the mobilization technique of PA or relaxation techniques of PIR, PRR on the SHOP is performed in the extensor position of the spine and lower extremities;

b) manipulations on the SHOP are performed in the extensor position of the spine and lower extremities on both sides;

c) the mobilization technique of PAR or relaxation techniques of PIR, PRR on the lower extremity (the muscles of the extensor, abducting and rotating the hip, the muscles of the extensor and flexor of the foot) are performed in the extensor position of the spine and lower extremities;

d) MPTP pressure on the lower limb and lower back is performed in the extensor position of the spine and lower extremities;

d) the mobilization technique of PA or relaxation techniques of PIR, PRR on the spine (GOP, POP) is performed in the extensor position of the spine and lower extremities;

e) the mobilization and manipulation of the KPS is performed in the extensor position of the spine and lower extremities;

f) GOP manipulations are performed in the extensor position of the spine and lower extremities;

g) POP skin mobilization is performed in the extensor position of the spine and lower extremities;

h) manipulations on healthy PDS POP are performed in the extensor position of the spine and lower extremities on both sides at the end of the course of treatment, as a final reception;

i) OPP manipulations are performed provided that the MPD POP hernias are without sequestration and their size is not more than 1 cm in depth.

At the same time, the extensor position of the spine, in which the extensor sanogenizing myofixation of PDS POP is preserved, during the implementation of the PAR technique, the author-applicant strengthens. For this, oculomotor synergies are used with participation in the extensor movement of the head, SHOP and GOP.

MT receptions are performed starting from the peripheral parts of the body (SHOP and lower limb) and ending in EPP.

3. MT tactics in identifying extravertebral syndromes anatomically associated with the lumbar and sacral plexuses.

This tactic option is suitable for patients who, during a neurological examination, have radicular, radicular-vascular and muscle syndromes anatomically associated with both the lumbar and sacral plexuses.

Examples of formulating diagnoses:

1. Discogenic radiculopathy L4-L5 on the left, stable course, stage of exacerbation, severe pain.

2. Osteochondrosis of the lumbar spine of 3 periods, sequestered right-sided disc herniation L3-L4, discogenic radiculopathy L4, L5 roots on the right with a pronounced paresis of extensors of the right foot, severe pain and vertebral syndromes.

In both examples of diagnoses, extravertebral syndromes play a major role in the choice of treatment tactics, since they indicate an anatomical connection with the lumbar (radiculopathy of the L4 root) and sacral (radiculopathy of the radicular L5) plexus.

Often a combination of radicular or radicular-vascular (compression) syndrome associated with one plexus is detected, and reflex (muscle) syndrome associated with another plexus.

An example of a diagnosis.

Osteochondrosis of the lumbar spine. Right-sided disc herniation L5-S1, median disc herniation L2-L3. Discogenic radiculoischemia of L5, S1 roots with moderate paresis of extensors and flexors of the right foot, ileo-lumbar muscle syndrome on the right, stage of regression, moderate pain.

In this diagnosis, extravertebral syndromes play a major role in the choice of treatment tactics, as they indicate an anatomical connection with the lumbar (iliopsoas muscle syndrome) and sacral (radiculoischemia L5, S1 roots) plexuses.

In all examples of diagnoses, patients have a neutral direction of myofixation of the lower limb and, accordingly, a neutral direction of sanogenizing myofixation in the damaged (damaged) PDS POP, as well as a neutral direction of myofixation of GOP and SHOP.

When identifying extravertebral syndromes anatomically associated with the lumbar and sacral plexuses, in order to maintain neutral sanogenizing myofixation in the damaged (damaged) PDP POP, which limits its (their) flexion and extension, the applicant uses the following tactics:

a) the mobilization technique of PAR or relaxation techniques of PIR, PRR at the SHOP is performed in the neutral position of the spine and lower extremities;

b) manipulations on the SHOP are performed in the neutral position of the spine and lower extremities on both sides;

c) the mobilization technique of PAR or relaxation techniques of PIR, PRR on the lower limb (muscles of the flexor and adductors of the thigh, muscles of the extensor, abducting and outwardly rotating the thigh, muscles of the extensor and flexor of the foot) are performed in the neutral position of the spine and lower extremities;

d) MPTP pressure on the lower limb and lower back is performed in a neutral position of the spine and lower extremities;

d) the mobilization technique of PA or relaxation techniques of PIR, PRR on the spine (GOP, POP) is performed in the neutral position of the spine and lower extremities;

f) mobilization and manipulation of the KPS is performed in the neutral position of the spine and lower extremities;

e) manipulations on the GOP are performed in the neutral position of the spine and lower extremities;

g) POP skin mobilization is performed in a neutral position of the spine and lower extremities;

h) manipulations on healthy PDS POP are performed in a neutral position of the spine and lower extremities on both sides at the end of the course of treatment, as a final reception;

i) OPP manipulations are performed provided that the MPD POP hernias are without sequestration and their size is not more than 1 cm in depth.

Experimental data confirming the hypothesis of dural-muscular-venous-lymphatic spinal pump.

To confirm the hypothesis of a dural-muscular-venous-lymphatic pump of the spine, experiments were carried out to measure the pressure values in the venous system of the spine when taking PAR. The technique used was: “Post-activation tension of the musculo-ligamentous apparatus of the thoracic, lumbar spine, pelvis, ileo-lumbar ligament with tension and vibrational displacement of the dural sac in rotation (in the flexion, extensor and neutral positions of the spine and lower extremities).”

Given the relationship between the system of vertebral venous plexuses (internal, external) and the venous system of the vertebra, the pressure in these systems can be considered the same. Therefore, by measuring the intraosseous venous pressure in the spinous processes of the lumbar vertebrae, we obtain information about the pressure in the venous system of POP. 36 measurements were performed through the spinous processes of the LIII, LIV, LV vertebrae in patients with protrusions, hernias, and sequestered hernias of the MPD POP.

During muscle contraction with inhalation and respiratory arrest (stages of isotonic and isometric activation), the intraosseous pressure in patients significantly increased ~ 1.5 times, while relaxing them with exhalation (the stage of repeated passive stretching) and subsequent being in the initial position of the body - it dropped below the initial level ~ 2 times. It should be noted that this sequence of changes in pressure values in the venous system of the spine was observed at the stage of disease regression. In the stage of exacerbation of the disease, especially in patients with sequestered hernias, the pump is disturbed, and significant changes in venous pressure were not observed.

Thus, additional data have been obtained that confirm the hypothesis of a dural-muscular-venous-lymphatic pump of the spine, since as a result of the experiments, the pressure in the venous POP system decreased below the initial level by a factor of 2.

The method is as follows.

If extravertebral syndromes anatomically associated with the lumbar plexus are identified, it is performed:

I. Post-activation stretching of the musculo-ligamentous apparatus of the cervical, upper thoracic spine and shoulder girdle with tension and vibrational displacement of the dural sac in rotation in the flexion position of the spine and lower extremities.

Starting position: the patient lies on his back. The patient's legs are bent at the knee and hip joints, the knees are brought to each other, and the feet are divorced, stand on the table and fixed with rubber clips. Under the basin lies an ergonomic roller. Due to the ergonomic roller under the pelvis, bent and brought legs bent POP. Under the patient’s head, neck, upper body are the ergonomic pillow and cushion. Due to this, the chin drops slightly, the SHOP and GOP are bent, and the POP is also bent. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the side of the patient’s head. Work is carried out, for example, on the left half of the neck. The doctor puts his right hand on the left side surface of the patient's face, the left - on the left shoulder joint in front and top. The patient directs his gaze to the right and down (oculomotor synergy), makes a smooth exhalation (respiratory synergy) and relaxes the muscles. The doctor turns his head to the right, and the left shoulder joint stretches back and down. The doctor conducts a smooth preliminary passive stretching of the musculo-ligamentous apparatus of the left half of the SHOP, the upper thoracic spine (spinal rotators) and the left shoulder girdle until the border of passive movement with moderate pain in the patient is reached. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (concave side of the spine) with compression of venous and lymphatic vessels in the epidural space on the concave side, with stretching of scars and adhesions in the epidural space. When working on the right side of the patient’s neck, the situation is mirrored. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks to the left and down (oculomotor synergy), takes a smooth breath (respiratory synergy) and simultaneously rotates the head in the same direction with a force of 50% of the maximum possible with overcoming the inferior resistance of the right hand of the doctor. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. A turn is made to a position in which the patient's face is facing forward, the chin is lowered. At the same time, the doctor leans back slightly and, using the weight of his body, performs inferior work. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed to the left side and down (oculomotor synergy). The face is forward, the chin is down. Due to the resistance of the doctor’s hands and the patient’s tension, the final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor slightly deviates back and, using the weight of his body, fixes this position. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks up and down (oculomotor synergy), exhales smoothly (breathing synergy), relaxes the muscles, and at the same time the doctor moves the patient's head and neck to the right. Upon reaching the initial border of passive movement, the doctor performs a smooth repeated passive stretching of the SHOP muscle and ligamentous apparatus and the upper thoracic spine (spinal rotators) in rotation with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor fixes the left side surface of the patient’s head with the right hand and the left shoulder joint in front of the patient with the left hand and leans forward slightly using his body weight, stretching the patient’s neck and shoulder girdle. It is necessary to strive for the maximum rotation of the head, SHOP and upper thoracic spine to the right. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (concave side of the spine) with compression of venous and lymphatic vessels in the epidural space on the concave side, with stretching of scars and adhesions in the epidural space. At the end of this stage, the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The joint amplitude of the movement of the SHOP, upper thoracic spine and shoulder girdle in rotation in the flexion position of the spine is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is carried out from two sides.

II. Post-activation stretching of the musculo-ligamentous apparatus of the cervical, upper thoracic spine and shoulder girdle with tension and vibrational displacement of the dural sac in lateroflexion in the flexion position of the spine and lower extremities lying down.

Starting position: the patient lies on his back. The patient's legs are bent at the knee and hip joints, the knees are brought to each other, and the feet are divorced, stand on the table and fixed with rubber clips. Under the basin lies an ergonomic roller. Due to the ergonomic roller under the pelvis, bent and brought legs bent POP. Under the patient’s head, neck, upper body are the ergonomic pillow and cushion. Due to this, the chin drops slightly, the SHOP and GOP are bent, and the POP is also bent. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the side of the patient’s head. Work is carried out, for example, on the left half of the neck. The doctor puts his right hand on the left lateral surface of the patient’s head, the left hand - on top of his left shoulder joint. The patient's gaze is directed to the right and down (oculomotor synergy), he performs a smooth exhalation (respiratory synergy) and relaxes the muscles. The doctor conducts a smooth preliminary passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine to the right, and the left shoulder girdle down, until the border of passive movement with moderate pain in the patient is reached. The doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. When working on the right side of the patient’s neck, the situation is mirrored. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks to the left and down (oculomotor synergy), takes a smooth breath (respiratory synergy) and simultaneously performs a movement in the opposite direction with a force of 50% of the maximum possible, overcoming the inferior resistance of the doctor’s hands. The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle depends on the border of passive movement achieved during preliminary passive stretching or repeated passive stretching. In this case, the patient’s left ear and left shoulder joint are moving towards each other and should be as close as possible. At the same time, the doctor leans forward slightly on the patient and, using the weight of his body, performs inferior work. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed to the left and down (oculomotor synergy). The patient’s left ear and left shoulder joint are brought together. Due to the resistance of the doctor’s hands and the patient’s tension, the final phase of the movement is maintained in isometric mode with an average force of 50% of the maximum possible. In this case, the doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks to the right and down (oculomotor synergy), makes a smooth exhalation (respiratory synergy), relaxes the muscles, and at the same time the doctor moves in the opposite direction (to the right). Upon reaching the old border of passive movement, the doctor, using the weight of his body, conducts a smooth repeated passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine sideways with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor fixes the left side surface of the patient’s head with the right hand, and fixes the patient’s left shoulder joint with the left hand from above and in front. It is necessary to strive to bring the head closer to the right shoulder joint. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the end of this stage, the doctor performs 5-10 swaying movements in the direction of the performed stretching, reinforcing this effect. The duration of the stage is 8-10 seconds.

The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle in lateroflexion varies from about 15 to 90 °. The number of repeated cycles is 3-5 in one session. The impact is carried out from two sides.

III. Post-activation stretching of the musculo-ligamentous apparatus of the cervical, upper thoracic spine and shoulder girdle with tension and vibrational displacement of the dural sac in flexion in the flexion position of the spine and lower extremities.

Starting position: the patient lies on his back. The patient's legs are bent at the knee and hip joints, the knees are brought to each other, and the feet are divorced, stand on the table and fixed with rubber clips. Under the basin lies an ergonomic roller. Due to the ergonomic roller under the pelvis, bent and brought legs bent POP. Under the patient’s head, neck, upper body are the ergonomic pillow and cushion. Due to this, the chin drops slightly, the SHOP and GOP are bent, and the POP is also bent. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the side of the patient’s head. The ergonomic roller is removed from under the patient’s head, the pillow is left. The doctor with his hands creates a tilt of the head forward and the flexion position of the SHOP. The doctor’s hands, folded into the lock, are located under the back of the head of the patient. The patient's gaze is directed down to the stomach (oculomotor synergy), while he performs a smooth exhalation (respiratory synergy) and relaxes the muscles. The doctor raises the patient's head, bringing his chin to his chest. The doctor fixes the nape of the patient with his own hands and stomach and performs a smooth preliminary passive stretching of the musculo-ligamentous apparatus of the cervical, upper thoracic spine in the direction of forward bending. Stretching is carried out until the border of passive movement with moderate pain in the patient is reached. In this case, the dural sac is stretched and displaced in the epidural space to the front wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks up at the ceiling (oculomotor synergy), takes a smooth breath (respiratory synergy) and at the same time performs extensor movement of the head and neck with a force of 50% of the maximum possible, overcoming the inferior resistance of the doctor’s hands. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. In this case, the cervical spine is straightened, the back of the patient's head approaches the pillow. At the same time, the doctor holds the patient’s head with his own hands, leans back slightly and, using the weight of his body, performs inferior work. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed upward at the ceiling (oculomotor synergy). Due to the resistance of the doctor’s hands and the patient’s tension, the rectified position of the cervical spine is maintained in isometric mode with a force of 50% of the maximum possible. At the same time, the doctor holds the patient’s head with his own hands, leans back slightly and, using the weight of his body, fixes this position. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks down at the stomach (oculomotor synergy), performs a smooth exhalation (respiratory synergy) and relaxes the muscles. At the same time, the doctor performs the flexion movement of the patient’s head and neck with his hands mounted on the back of his head. Upon reaching the old border of passive movement, the doctor performs a smooth repeated passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine with a strength of 50% of the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor fixes the patient’s neck with his stomach, puts his hands on the shoulder joints, leans slightly forward and, using the weight of his body, smoothly stretches his neck and shoulders. You must strive to put the patient's chin on his chest. In this case, the dural sac is stretched and displaced in the epidural space to the front wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the end of this stage, the doctor performs 5-10 swaying movements in the direction of the performed stretching to enhance the effect. The duration of the stage is 8-10 seconds.

The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle in flexion ranges from about 15 to 90 °. The number of repeated cycles is 3-5 in one session.

IV. Manipulation treatment of the upper and middle cervical spine in the flexion position of the spine and lower extremities lying down.

Receptions I, II and III contribute to the improvement of blood supply (an equilibrium is achieved between the arterial inflow and venous, lymphatic outflow), stretching of the musculo-ligamentous apparatus of these departments and serve as preparation for subsequent safe manipulations.

Starting position: the patient lies on his back. The patient's legs are bent at the knee and hip joints, the knees are brought to each other, and the feet are divorced, stand on the table and fixed with rubber clips. Under the basin lies an ergonomic roller. Due to the ergonomic roller under the pelvis, bent and brought legs bent POP. Under the patient’s head, neck, upper body are the ergonomic pillow and cushion. Due to this, the chin drops slightly, the SHOP and GOP are bent, and the POP is also bent. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

The ergonomic roller is removed from under the patient’s head, the pillow is left. The doctor with his hands creates a tilt of the head forward and the flexion position of the SHOP. The patient is manipulated on the upper and middle cervical spine using rotation and tracking from two sides.

The number of PDS on which manipulations can be performed depends on the stage of myofixation in which the patient is located.

V. Post-activation tension of the musculo-ligamentous apparatus of the cervical, upper thoracic spine and shoulder girdle with tension and vibrational displacement of the dural sac in lateroflexion in the flexion position of the spine and lower extremities sitting.

This technique is not recommended for use in the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the lumbar intervertebral discs, when the patient’s sitting position, resting on a sore buttock, intensifies the pain syndrome.

In the regression stage of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can sit without intensifying the pain syndrome, a pose is used in the flexion position of the spine and lower limbs while sitting. There are two possible options for the starting position.

Starting position No. 1: the patient sits on the table with his back to the doctor, bending over and tilting his head forward. The doctor puts one leg, bent at the knee joint, with his foot on the couch on the side and in front of the patient, the patient throws his hand over the doctor’s thigh, leaning on it. Due to the support on the thigh of the doctor, located on the side and in front of the patient, and the inclination of the head forward, the patient's SHOP, GOP and POP are bent. Bent legs, bent SHOP, GOP and POP of the patient forms the flexion position of the spine and lower extremities.

Starting position No. 2: the patient sits on the table with his back to the doctor, bending over and tilting his head forward. The patient puts one arm, straightened in the elbow joint, on the side and front of himself, leaning on it. Due to the support on his hand, located on the side and in front of the patient and tilting the head forward, the patient’s SHOP, GOP and POP are bent. Bent legs, bent SHOP, GOP and POP of the patient forms the flexion position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor is standing on the patient’s back. If the patient rests with his right hand, then the work is done on the left half of the neck and vice versa. Work is carried out, for example, on the left half of the neck. The doctor puts his right hand on the left lateral surface of the patient’s head, the left hand - on top of his left shoulder joint. The patient's gaze is directed to the right and down (oculomotor synergy), he performs a smooth exhalation (respiratory synergy) and relaxes the muscles. The doctor conducts a smooth preliminary passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine to the right, and the left shoulder girdle down, until the border of passive movement with moderate pain in the patient is reached. The doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. When working on the right side of the patient’s neck, the situation is mirrored. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks to the left and down (oculomotor synergy), takes a smooth breath (respiratory synergy) and simultaneously performs a movement in the opposite direction with a force of 50% of the maximum possible, overcoming the inferior resistance of the doctor’s hands. The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle depends on the border of passive movement achieved during preliminary passive stretching or repeated passive stretching. In this case, the patient’s left ear and left shoulder joint are moving towards each other and should be as close as possible. At the same time, the doctor leans forward slightly on the patient and, using the weight of his body, performs inferior work. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed to the left and down (oculomotor synergy). The patient’s left ear and left shoulder joint are brought together. Due to the resistance of the doctor’s hands and the patient’s tension, the final phase of the movement is maintained in isometric mode with an average force of 50% of the maximum possible. In this case, the doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks to the right and down (oculomotor synergy), makes a smooth exhalation (respiratory synergy), relaxes the muscles, and at the same time the doctor moves in the opposite direction (to the right). Upon reaching the old border of passive movement, the doctor, using the weight of his body, conducts a smooth repeated passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine sideways with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor fixes the left side surface of the patient’s head with the right hand, and fixes the patient’s left shoulder joint with the left hand from above and in front. It is necessary to strive to bring the head closer to the right shoulder joint. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the end of this stage, the doctor performs 5-10 swaying movements in the direction of the performed stretching, reinforcing this effect. The duration of the stage is 8-10 seconds.

The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle in lateroflexion varies from about 15 to 90 °. The number of repeated cycles is 3-5 in one session. The impact is carried out from two sides.

VI. Manipulation treatment of the cervicothoracic junction and cervical spine in the flexion position of the spine and lower limbs sitting.

Receptions I, II, III and V contribute to the improvement of blood supply (an equilibrium is achieved between the arterial inflow and venous, lymphatic outflow), stretching of the musculo-ligamentous apparatus of these departments and serve as preparation for subsequent safe manipulations.

Starting position: the patient sits on the table, bending his body and tilting his head forward, while shifting the body weight back and leaning his back on the doctor. Due to this, the SHOP, GOP and POP of the patient are bent. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

A) The patient is performed nonspecific manipulations on the cervicothoracic junction using rotation, distraction and counter-retention in the position of the patient sitting on both sides. During the execution of the manipulations, the patient's body falls down and the flexion position of the spine increases.

B) In the same initial position, the patient can perform nonspecific manipulations on the upper and middle cervical spine using rotation, distraction and counter-retention in the position of the patient sitting on both sides. During the execution of the manipulations, the patient's body falls down and the flexion position of the spine increases. Manipulations on the upper and middle cervical spine in the sitting position duplicate the manipulations in the supine position, since it happens that the manipulations do not work out in one position, but go out in another.

The number of PDS on which manipulations can be performed depends on the stage of myofixation in which the patient is located.

VII. Post-activation stretching of the inner group of the musculo-ligamentous apparatus of the thighs (adductor muscles) and the hip joints in abduction in the flexion position of the spine and lower extremities.

Starting position: the patient lies on his back. The patient's legs are bent at the knee and hip joints, the knees are brought to each other, and the feet are divorced, stand on the table and fixed with rubber clips. Under the basin lies an ergonomic roller. Due to the ergonomic roller under the pelvis, bent and brought legs bent POP. Under the patient’s head, neck, upper body are the ergonomic pillow and cushion. Due to this, the chin drops slightly, the SHOP and GOP are bent, and the POP is also bent. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor sits astride the table, facing the patient's legs. The doctor’s hands are located on the inner surface of the patient’s knees. The patient’s hands are on the inner surface of both thighs. The patient’s face and gaze are directed forward and upward (oculomotor synergy), he exhales (respiratory synergy) and relaxes the muscles. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The doctor leans forward slightly and with both hands spreads the patient's knees, bringing his hips closer to the table (abduction - abduction). The doctor conducts a smooth preliminary passive stretching of the inner group of the musculo-ligamentous apparatus of the thighs and hip joints (adductor muscles) until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks down to his stomach (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head rises and leans forward, SHOP and GOP are bent. SHOP and GOP are bent to an angle of 40-45 ° due to the tension of the flexor muscles of the spine and abdominal muscles. In this case, the dural sac is stretched and displaced in the epidural space to the front wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the same time, the patient performs movement in the hip joints (adduction - adduction), bringing the knees closer to each other with a force of 50% of the maximum possible. The amplitude of the movement depends on the boundary of the passive movement achieved during the preliminary passive extension or repeated passive extension. In this case, the doctor leans forward slightly and, using the weight of his body, exerts resistance. The patient's hands resist the approaching hips, which reduces the physical effort of the doctor. The duration of the stage is 4-5 seconds. The bending position of the spine increases.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed down to his stomach (oculomotor synergy), his head is raised and tilted forward, SHOP and GOP are bent. The reinforced flexion position of the spine is maintained. SHOP and GOP are bent to an angle of 40-45 ° and are held due to the tension of the flexor muscles of the spine and abdominal muscles. In this case, the dural sac is stretched and located near the front wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. Patient's knees are close to each other. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans forward slightly and, using the weight of his body, fixes this position with his hands. At the same time, the patient holds his hips with his hands, which reduces the physical effort of the doctor. The duration of the stage is 4-5 seconds. The bending position of the spine increases.

4. Repeated passive stretching.

The patient returns a look forward and upward (oculomotor synergy), performs a smooth exhalation (respiratory synergy) and relaxes the muscles, while his head returns to its original position. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. At the same time, the doctor moves the patient's knees in the opposite direction (abduction - abduction). Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the internal group of the musculo-ligamentous apparatus of the thighs and hip joints (adductors). The impact is carried out with a force of 50% from the maximum possible to a new border of movement with moderate pain in the patient. It is necessary to strive as much as possible, to bring the patient's hips closer to the table. The relaxed hands of the patient retain their position on the inner surface of the thighs. The doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of the movement of the hips in abduction-adduction is 15-70 °. The number of repeated cycles is 3-5 in one session. The impact is performed simultaneously on both legs.

At the end of the procedure, the patient is left knees in the breeding position, while the hips are close to the table. His hands are on the inner surface of both thighs as a burden. The patient relaxes and breathes calmly for 3-5 minutes. This exposure element greatly enhances the tensile effect.

Viii. Post-activation stretching of the iliopsoas muscle, the anterior group of the musculo-ligamentous apparatus of the thigh (hip flexors) and the hip joint in extension in the flexion position of the spine and lower extremities.

Starting position: the patient lies on his back, the pelvis at the level of the sciatic tubercles is on the edge of the table. Under the basin lies an ergonomic roller. The patient's legs are bent at the hip and knee joints, fixed by the hands on the knees, brought to each other and pressed to the stomach. Due to the ergonomic roller under the pelvis, bent and brought legs bent POP. Under the patient’s head, neck, upper body are the ergonomic pillow and cushion. Due to this, the chin drops slightly, the SHOP and GOP are bent, and the POP is also bent. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s legs. A healthy leg remains bent at the hip and knee joints. The patient’s brush of the same name is located on the lower third of the thigh near the knee, and the counter-brush on the foot of a healthy leg. The patient’s diseased leg, starting from the gluteal fold, hangs and is located outside the table. It is unbent at the hip and bent at the knee joints. One hand of the doctor rests his elbow (transferring the weight of the upper part of the body) to the knee joint from the lower leg of the patient’s healthy bent leg, the other hand with his palm or fist rests just above the knee joint from the hip side of the patient’s sore leg. The patient’s face and gaze are directed forward and upward (oculomotor synergy), he exhales (respiratory synergy) and relaxes the muscles. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The doctor presses a hand on a sore leg, moving it down and simultaneously fixing the knee of a healthy leg. At the same time, the doctor conducts a smooth preliminary passive stretching of the ileo-lumbar muscle, muscular-ligamentous apparatus of the anterior thigh and hip joint (hip flexors) of the sore leg until the patient reaches the border of passive movement with moderate pain. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks down to the stomach (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head rises and leans forward, SHOP and GOP are additionally bent. SHOP and GOP are bent to an angle of 40-45 ° due to the tension of the flexor muscles of the spine and abdominal muscles. In this case, the dural sac is stretched and displaced in the epidural space to the front wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the same time, the patient begins to press the extended leg against the fixing palm or fist of the doctor with a straightened thigh with a force of 50% of the maximum possible, bending it in the hip joint. One hand of the doctor lies on the knee joint from the side of the patient's thigh, giving him inferior resistance, the other presses with his elbow on the knee joint from the shin, fixing the bent healthy leg. There is tension and contraction of the musculo-ligamentous apparatus of the iliopsoas muscle, the anterior surface of the thigh (hip flexors) and the hip flexion in the hip joint to the stop in the counter foot. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. At the same time, the doctor leans forward slightly and, using the weight of his body, counteracts. The duration of the stage is 4-5 seconds. The bending position of the spine increases.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed down to his stomach (oculomotor synergy), his head is raised and tilted forward, SHOP and GOP are bent. The reinforced flexion position of the spine is maintained. SHOP and GOP are bent to an angle of 40-45 ° and are held due to the tension of the flexor muscles of the spine and abdominal muscles. In this case, the dural sac is stretched and located near the front wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. The final phase of hip flexion is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans forward slightly and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds. The bending position of the spine increases.

4. Repeated passive stretching.

The patient returns a look forward and upward (oculomotor synergy), performs a smooth exhalation (respiratory synergy) and relaxes the muscles, while his head returns to its original position. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. At the same time, the doctor moves the patient's hips down in the opposite direction. Upon reaching the old border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the ileo-lumbar muscle, the anterior group of the musculo-ligamentous apparatus of the thigh and hip joint (hip flexors). The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. The doctor tries to bring the hip of the sore leg closer to the floor. Then the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of the femur in extensional flexion is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

At the end of the procedure, the patient is left with a sore leg hanging over the side of the table. It is bent at the hip, bent at the knee joints and stretched under its own weight. The hands fix the bent knee of a healthy leg. The patient relaxes and breathes calmly for 3-5 minutes. This exposure element greatly enhances the tensile effect.

IX. Post-activation stretching of the anterior group of the musculo-ligamentous apparatus of the thigh, lower leg (hip flexors, extensors of the lower leg and foot), knee and ankle joints in flexion in the flexion position of the spine and lower extremities.

This technique cannot be used at the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the lumbar intervertebral discs, since patients cannot lie on the stomach due to flexion myofixation of the lower extremities and spine.

In the regression stage of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can lie on their stomachs, the option of laying in the flexion position of the spine and lower extremities is used.

Starting position: the patient lies on his stomach, his legs lie on the table. The forehead and the back of the nose are on the table, due to this, the chin drops slightly and bends SHOP, as well as GOP. Crossed hands lie on the table in front of the crown of the head. An ergonomic pillow and cushion lie under the patient’s stomach and pelvis. Due to this, POP is bent. The legs are slightly bent, brought to each other and lie on the table. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

1. Preliminary passive stretching.

The patient’s patient’s leg bends at a 90 ° angle in the knee joint, and the foot is in a state of plantar flexion. The patient’s face and gaze are directed down to the table; he exhales smoothly (breathing synergy) and relaxes the muscles. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The doctor fixes the patient’s foot lift with one hand, puts the other hand on the wrist joint of the working hand and performs a smooth preliminary passive stretching of the anterior group of the musculo-ligamentous apparatus of the thigh, lower leg, knee and ankle joints (hip flexors, extensors of the lower leg and foot) of the affected leg. In this case, the doctor brings the heel of the affected leg closer to the buttock until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks down at the stomach (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head rests his forehead on the table, his chin drops, and the SHOP and GOP are bent. SHOP and GOP are bent to an angle of 40-45 ° due to the tension of the flexor muscles of the spine and abdominal muscles. In this case, the dural sac is stretched and displaced in the epidural space to the front wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the same time, the patient performs extension of the affected leg in the ankle and knee joints with a force of 50% from the maximum possible to an angle of 75-80 ° (between the thigh and lower leg, between the lower leg and foot). In this case, the doctor leans forward slightly and, using the weight of his body, performs inferior work. The amplitude of motion of the sore leg depends on the border of passive movement achieved during preliminary passive stretching or repeated passive stretching. The duration of the stage is 4-5 seconds. The bending position of the spine increases.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed down at the stomach (oculomotor synergy), his head is lowered forehead to the table, and the SHOP and GOP are bent. The reinforced flexion position of the spine is maintained. SHOP and GOP are bent to an angle of 40-45 ° and are held due to the tension of the flexor muscles of the spine and abdominal muscles. In this case, the dural sac is stretched and located near the front wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. The angle of 75-80 ° between the lower leg and thigh, lower leg and foot of the patient allows the doctor to effectively use his body weight for resistance and spend less energy. In this case, the doctor leans forward slightly and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient returns his gaze down to the table (oculomotor synergy), makes a smooth exhalation (respiratory synergy), relaxes the muscles, the head moves back and rests his forehead on the hands crossed in front of him. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. At the same time, the doctor moves the patient's foot and lower leg in the opposite direction to his buttock. Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the anterior group of the musculo-ligamentous apparatus of the thigh, lower leg, knee and ankle joints (hip flexors, extensors of the lower leg and foot) of the sore leg. Stretching is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor seeks to perform plantar flexion of the foot and put the heel on the patient’s buttock. After that, to increase the effectiveness of stretching, the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of movement of the lower leg and foot in flexion-extension is approximately 15-45 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

X. Post-activation stretching of the external obturator muscles and the musculo-ligamentous apparatus of the gluteal regions (the hips that rotate and divert outside), the hip, knee joints in abduction in the flexion position of the spine and lower extremities.

This technique cannot be used at the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the lumbar intervertebral discs, since patients cannot lie on the stomach due to flexion myofixation of the lower extremities and spine.

In the regression stage of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can lie on their stomachs, the option of laying in the flexion position of the spine and lower extremities is used.

Starting position: the patient lies on his stomach, his legs lie on the table. The forehead and the back of the nose are on the table, due to this, the chin drops slightly and bends SHOP, as well as GOP. Crossed hands lie on the table in front of the crown of the head. An ergonomic pillow and cushion lie under the patient’s stomach and pelvis. Due to this, POP is bent. The legs are slightly bent, brought to each other and lie on the table. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

1. Preliminary passive stretching.

The patient's legs are bent at the knee at a right angle, the knees are closed. The doctor sits on the table, fixing with his hands the internal ankles of the patient. The patient's gaze is directed down to the table, he makes a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The doctor conducts a smooth preliminary passive stretching of the external obturator muscles and the musculo-ligamentous apparatus of the gluteal regions (the hips that rotate and diverts outwards), the hips and knees, spreading the legs and feet outward to reach the border of passive movement with moderate pain in the patient. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks down at the stomach (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head rests his forehead on the table, his chin drops, and the SHOP and GOP are bent. SHOP and GOP are bent to an angle of 40-45 ° due to the tension of the flexor muscles of the spine and abdominal muscles. In this case, the dural sac is stretched and displaced in the epidural space to the front wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the same time, the patient performs a smooth movement with a force of 50% of the maximum possible to reduce the legs and feet to each other. The amplitude of the legs depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. In this case, the doctor leans forward slightly and, using the weight of his body, performs inferior work. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed down at the stomach (oculomotor synergy), his head is lowered forehead to the table, and the SHOP and GOP are bent. The reinforced flexion position of the spine is maintained. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. SHOP and GOP are bent to an angle of 40-45 ° and are held due to the tension of the flexor muscles of the spine and abdominal muscles. In this case, the dural sac is stretched and located near the front wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. The legs are bent at the knees at a right angle, the knees are closed, the legs and feet are close to each other. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient returns a look down to the table (oculomotor synergy), makes a smooth exhalation (respiratory synergy), relaxes the muscles, the head moves back, the forehead and the back of the nose rests on the table. Crossed hands lie on the table in front of the crown of the head. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. At the same time, the doctor performs a smooth movement of his lower legs in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the external obturator muscles and the musculo-ligamentous apparatus of the gluteal regions (abduction and outward-rotating thigh), hip and knee joints with a force of 50% of the maximum possible to a new border of passive movement with moderate pain in the patient. It is necessary to strive to bring the feet closer to the table. Then the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of motion of both legs in abduction-adduction is approximately 15-50 °. The number of repeated cycles is 3-5 in one session. The impact is performed simultaneously on both legs.

Xi. Pressurization of myofascial trigger points in the flexion position of the spine and lower extremities.

Starting position: the patient lies on his back. The patient's legs are bent at the knee and hip joints, the knees are raised, and the feet are divorced, standing on the table and fixed with rubber clips. Under the basin lies an ergonomic roller. Due to the ergonomic roller under the pelvis, bent and brought legs bent POP. Under the patient’s head, neck, upper body are the ergonomic pillow and cushion. Due to this, the chin drops slightly, the SHOP and GOP are bent, and the POP is also bent. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

The doctor rises from the affected leg and palpation determines MPTP. Most often they are located on the front-side surface of the thigh. There may be other localizations of MPTP, in particular, on the inner surface of the thigh. In this case, the knees are bent apart before holding the pressures.

The bent finger in the first interphalangeal joint III finger slowly begin to exert pressure on the trigger zone. The pressure intensity within 1 minute should increase to 10-15 kg. It is necessary to choose the direction of pressure in the direction of solid tissue (bone, ligament, fascia), avoiding direction in the direction of large vessels and nerves. The duration of the procedure is 3-5 minutes.

XII. Post-activation stretching of the musculo-ligamentous apparatus of the thoracic, lumbar spine, pelvis, ileo-lumbar ligament with tension and vibrational displacement of the dural sac in rotation in the flexion position of the spine and lower extremities.

Starting position: the patient lies on a sick (let's say - left) side. The lower leg bent at the hip joint, the leg straightened at the knee joint and the patient's body are placed at an angle closer to the straight line, open anteriorly. Due to the bent underlying leg bent POP. The patient's overlying leg is bent at the hip and knee joints, her foot lies in the popliteal fossa. The head rests on an ergonomic roller and leans forward, the chin drops slightly. Due to this, SHOP and GOP are bent, and also POP is additionally bent. Legs bent at the hip joints, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the back of the patient. The patient's body is deployed towards the doctor, while the face and chest are directed to the ceiling. The hand nearest to the doctor is bent at the elbow and set aside, and the far hand rests with the palm on the stomach. The doctor fixes the elbow of the near hand with his hand, bringing it closer to the table. A wrist or fist of the doctor’s other hand fixes the patient’s knee joint from above and also brings it closer to the table. The patient looks to the right and down (oculomotor synergy), makes a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles. The doctor conducts a smooth preliminary passive stretching of the right half of the muscular-ligamentous apparatus of the GOP, POP (spinal rotators), pelvis and ileo-lumbar ligament in rotation with flexion of the POP until the border of passive movement with moderate pain in the patient is reached. In this case, the doctor enhances the turn of the patient's body, bringing his near elbow and knee of the overlying leg to the table. The spine takes the form of the letter S with the left concave side of the deformity in POP and GOP. In this case, the dural sac is stretched and displaced in the epidural space to the left side wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space on the concave side, with stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks away from the doctor - to the left and down to the foot (oculomotor synergy), takes a smooth breath (respiratory synergy) and at the same time carries out a smooth rotational movement with the body and leg with a force of 50% of the maximum possible. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. The chest and head rotate from the doctor; overlying leg and pelvis - to the doctor, resting on the foot. In the final phase of the movement, the patient’s face and chest are deployed from the doctor, and the pelvis and knee to the doctor, with the knee pointing to the ceiling. POP is in a state of flexion, while the lumbar lordosis is smoothed or kyphosed. The patient’s near arm is wrapped behind the back, and her elbow is fixed with the doctor’s brush. The knee rests on the doctor’s straightened hand, the foot rests on the table and the doctor’s fist standing on the table. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. At the same time, the doctor leans forward slightly and, using the weight of his body, performs inferior work. The duration of the stage is 4-5 seconds. The bending position of the spine increases.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed away from the doctor - to the left and down to the foot (oculomotor synergy). The doctor leans forward slightly and, using his weight, fixes the final phase of the patient's rotational movement in isometric mode with a force of 50% of the maximum possible. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds. The bending position of the spine increases.

4. Repeated passive stretching.

The patient looks up and to the right (oculomotor synergy), performs a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles, while the doctor performs a smooth rotational movement of the patient's body in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the muscular-ligamentous apparatus of the GOP, POP (spinal rotators), pelvis and ileo-lumbar ligament in rotation with flexion of the POP. The impact is carried out with a force of 50% of the maximum possible, achieving a new border for passive movement with moderate pain in the patient. Fixation of the patient’s near arm behind the back stops, and the elbow is moved to the side, fixation of the arm farthest to the doctor on the stomach remains. In this case, it is necessary to strive so that the knee of the overlying leg and the elbow of the hands closest to the doctor are pressed against the table. The spine takes the form of the letter S with the left concave side of the deformity in the GOP and POP. In this case, the dural sac is stretched and displaced in the epidural space to the left side wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space on the concave side, with stretching of scars and adhesions in the epidural space.

At the end of this stage, the doctor performs 5-10 swaying movements in the same direction, enhancing the effect of stretching. The duration of the stage is 8-10 seconds.

The joint amplitude of movement of the HOP, POP and the pelvis of the patient in rotation in the flexion position of the spine is 15-90 °. The number of repeated cycles is 3-5 in one session. The exposure is performed first on the healthy and then on the diseased half of the spine with a stronger stretch on the diseased side. In the presence of analgesic scoliosis, the effect is performed on only one side - on the concave side of the deformation. At the end of the procedure, the patient is put on a rubber retainer on the shin of the overlying leg, and a sports weighting agent weighing 3-5 kg is placed on top of her thigh. The patient is given the overlying arm to the side and upward at an angle of 45 °, he relaxes and breathes calmly for 3-5 minutes. This exposure element greatly enhances the tensile effect.

Xiii. Mobilization of the sacroiliac joints of the pelvis in the flexion position of the spine and lower extremities.

At the stage of regression of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can lie on their stomachs, one option can be applied in the folding position of the spine and lower extremities.

A) Mobilization of the blocked CPS in the patient’s supine position.

Starting position No. 1: the patient lies on his stomach, his legs lie on the table. The forehead and the back of the nose are on the table, due to this, the chin drops slightly and bends SHOP, as well as GOP. Crossed hands lie on the table in front of the crown of the head. An ergonomic pillow and cushion lie under the patient’s stomach and pelvis. Due to this, POP is bent. The legs are slightly bent, brought to each other and lie on the table. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

The doctor mobilizes the blocked KPS according to V. Schneider and (or) according to A. Stoddart.

At the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients cannot lie on the abdomen due to flexion myofixation of the lower limb, two other options for laying in the flexion position of the spine and lower extremities are used.

B) Mobilization of blocked KPS in the patient's supine position.

Starting position No. 2: the patient lies on his back. The patient's legs are bent at the knee and hip joints, the knees are brought to each other, and the feet are divorced, stand on the table and fixed with rubber clips. Under the basin lies an ergonomic roller. Due to the ergonomic roller under the pelvis, bent and brought legs bent POP. Under the patient’s head, neck, upper body are the ergonomic pillow and cushion. Due to this, the chin drops slightly, the SHOP and GOP are bent, and the POP is also bent. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

The foot of a healthy leg remains fixed with a rubber retainer, and the foot of a sore foot is released. The doctor mobilizes the blocked CPS using the patient’s bent, injured leg as a lever.

C) It is also possible to carry out the mobilization of the blocked CPS in the position of the patient lying on his side.

Starting position No. 3: the patient lies on his side. The lower leg bent at the hip joint, the leg straightened at the knee joint and the patient's body are placed at an angle closer to the straight line, open anteriorly. Due to the bent underlying leg bent POP. The patient's overlying leg is bent at the hip and knee joints, her foot lies in the popliteal fossa. The head rests on an ergonomic roller and leans forward, the chin drops slightly. Due to this, SHOP and GOP are bent, and also POP is additionally bent. Legs bent at the hip joints, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

The doctor mobilizes the blocked CPS using the patient’s superior iliac wing as a lever.

Sometimes mobilization ends with manipulation. Receptions are repeated 10-30 times.

Xiv. Manipulation treatment of the thoracic spine in the flexion position of the spine and lower extremities.

Reception XII helps to improve blood supply (a balance is achieved between arterial inflow and venous, lymphatic outflow), stretching the muscular-ligamentous apparatus of the HOP and serves as a preparation for subsequent safe manipulations.

At the stage of regression of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can lie on their stomachs, one version of laying in the flexion position of the spine and lower extremities is used.

Starting position No. 1: the patient lies on his stomach, his legs lie on the table. The forehead and the back of the nose are on the table, due to this, the chin drops slightly and bends SHOP, as well as GOP. Crossed hands lie on the table in front of the crown of the head. An ergonomic pillow and cushion lie under the patient’s stomach and pelvis. Due to this, POP is bent. The legs are slightly bent, brought to each other and lie on the table. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

At the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients cannot lie on the stomach due to flexion myofixation of the lower extremities and the spine, another variant of laying in the flexion position of the spine and lower extremities is used.

Starting position No. 2: the patient lies with his chest and upper abdomen on the table. The forehead and the back of the nose are on the table, due to this, the chin drops slightly and bends SHOP, as well as GOP. Crossed hands lie on the table in front of the crown of the head. An ergonomic pillow lies under the patient’s stomach and pelvis. The pelvis hangs from the edge of the table, the legs bent at the hip and knee joints are lowered from the table, the knees are slightly brought together, the heels are divorced, and the feet are supported with socks on the floor. Due to the hanging pelvis, bent and reduced legs POP bends. Bent and reduced legs, a pelvis hanging from the edge of the table, bent POP, GOP, and SHOP of the patient form the flexion position of the spine and lower extremities.

The patient turns his head on his side, stretches his arms along the body, puts his hands under the anterior inner thighs. The patient undergoes targeted manipulations on the GOP using rotation and short levers.

The number of PDS on which manipulations can be performed depends on the stage of myofixation in which the patient is located.

Xv. Mobilization of the skin of the lumbar spine in the flexion position of the spine and lower extremities.

At the stage of regression of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can lie on their stomachs, one version of laying in the flexion position of the spine and lower extremities is used.

Starting position No. 1: the patient lies on his stomach, his legs lie on the table. The forehead and the back of the nose are on the table, due to this, the chin drops slightly and bends SHOP, as well as GOP. Crossed hands lie on the table in front of the crown of the head. An ergonomic pillow and cushion lie under the patient’s stomach and pelvis. Due to this, POP is bent. The legs are slightly bent, brought to each other and lie on the table. Bent and reduced legs, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

At the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients cannot lie on the stomach due to flexion myofixation of the lower extremities and the spine, another variant of laying in the flexion position of the spine and lower extremities is used.

Starting position No. 2: the patient lies with his chest and upper abdomen on the table. The forehead and the back of the nose are on the table, due to this, the chin drops slightly and bends SHOP, as well as GOP. Crossed hands lie on the table in front of the crown of the head. An ergonomic pillow lies under the patient’s stomach and pelvis. The pelvis hangs from the edge of the table, the legs bent at the hip and knee joints are lowered from the table, the knees are slightly brought together, the heels are divorced, and the feet are supported with socks on the floor. Due to the hanging pelvis, bent and reduced legs POP bends. Bent and reduced legs, a pelvis hanging from the edge of the table, bent POP, GOP, and SHOP of the patient form the flexion position of the spine and lower extremities.

The doctor palpation forms a fold of the skin and performs its displacement above the spinous processes of the upper sacral, lumbar and lower thoracic vertebrae. In this case, the skin stretches with a characteristic sound phenomenon in the form of a click. Reception is repeated 3 times.

Xvi. Manipulation treatment of the lumbar spine in the flexion position of the spine and lower extremities.

By the end of treatment, POP contracture is eliminated and the use of POP manipulations becomes possible. Receptions XII and XV contribute to the improvement of blood supply (a balance is achieved between arterial inflow and venous, lymphatic outflow), stretching of the musculo-ligamentous apparatus, skin POP and serve as a preparation for subsequent safe manipulations.

Starting position: the patient lies on a sick (let's say - left) side. The lower leg bent at the hip joint, the leg straightened at the knee joint and the patient's body are placed at an angle closer to the straight line, open anteriorly. Due to the bent underlying leg bent POP. The patient's overlying leg is bent at the hip and knee joints, her foot lies in the popliteal fossa. The head rests on an ergonomic roller and leans forward, the chin drops slightly. Due to this, SHOP and GOP are bent, and also POP is additionally bent. Legs bent at the hip joints, bent POP, GOP and SHOP of the patient form the flexion position of the spine and lower extremities.

The patient’s overlying leg, bent at the hip and straightened at the knee joints, is lowered and placed outside the table. The patient is manipulated on healthy lumbar PDS on both sides using rotation and flexion. Manipulation of POP is performed provided that the hernias of MPD POP without sequestration and their size is not more than 1 cm in depth.

The number of PDS on which manipulations can be performed depends on the stage of myofixation in which the patient is located.

If extravertebral syndromes anatomically associated with the sacral plexus are identified, it is performed:

I. Post-activation stretching of the musculo-ligamentous apparatus of the cervical, upper thoracic spine and shoulder girdle with tension and vibrational displacement of the dural sac in rotation in the extensor position of the spine and lower extremities.

Starting position: the patient lies on his back with legs straightened and slightly divorced. Five ergonomic ridges lie under his neck, lower back, upper thighs, knees and Achilles tendons. Due to the ergonomic rollers under the lower back and neck, POP and SHOP are unbent, the chin is slightly raised. Due to the ergonomic rollers under the upper thighs, knees and Achilles tendons, the lower limbs are unbent, and the intensification of pain during extension of the POP is prevented. The patient’s extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the side of the patient’s head. Work is carried out, for example, on the left half of the neck. The doctor puts his right hand on the left side surface of the patient's face, the left - on the left shoulder joint in front and top. The patient directs his gaze to the right and up (oculomotor synergy), makes a smooth exhalation (respiratory synergy) and relaxes the muscles. The doctor turns his head to the right, and the left shoulder joint stretches back and down. The doctor performs a smooth preliminary passive stretching of the musculo-ligamentous apparatus of the left half of the SHOP, the upper thoracic spine and the left shoulder girdle in rotation with the extension of the SHOP until the border of passive movement with moderate pain in the patient is reached. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. When working on the right side of the patient’s neck, the situation is mirrored. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks to the left and up (oculomotor synergy), takes a smooth breath (respiratory synergy) and at the same time performs a smooth turn of the head in the same direction with a force of 50% of the maximum possible with overcoming the inferior resistance of the right hand of the doctor. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. The rotation is made to a position in which the patient's face is facing up. At the same time, the doctor leans back slightly and, using the weight of his body, performs inferior work. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed to the left side and up (oculomotor synergy). The face is facing up. Due to the resistance of the doctor’s hands and the patient’s tension, the final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor slightly deviates back and, using the weight of his body, fixes this position. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks up and to the right (oculomotor synergy), exhales smoothly (respiratory synergy), relaxes the muscles, and at the same time the doctor makes the patient's head and neck move to the right. Upon reaching the initial border of passive movement, the doctor conducts a smooth repeated passive stretching of the SHOP muscle and ligamentous apparatus and upper thoracic spine in rotation with the extension of the SHOP with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor fixes the left side surface of the patient’s head with the right hand and the left shoulder joint in front of the patient with the left hand and leans forward slightly using his body weight, stretching the patient’s neck and shoulder girdle. It is necessary to strive for the maximum rotation of the head, SHOP and upper thoracic spine to the right. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the end of this stage, the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The joint amplitude of the movement of the SHOP, upper thoracic spine and shoulder girdle in rotation in the extensor position of the spine is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is carried out from two sides.

II. Post-activation stretching of the musculo-ligamentous apparatus of the cervical, upper thoracic spine and shoulder girdle with tension and vibrational displacement of the dural sac in lateral flexion in the extensor position of the spine and lower extremities lying down.

Starting position: the patient lies on his back with legs straightened and slightly divorced. Five ergonomic ridges lie under his neck, lower back, upper thighs, knees and Achilles tendons. Due to the ergonomic rollers under the lower back and neck, POP and SHOP are unbent, the chin is slightly raised. Due to the ergonomic rollers under the upper thighs, knees and Achilles tendons, the lower limbs are unbent, and the intensification of pain during extension of the POP is prevented. The patient’s extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the side of the patient’s head. Work is carried out, for example, on the left half of the neck. The doctor puts his right hand on the left lateral surface of the patient’s head, the left hand - on top of his left shoulder joint. The patient's gaze is directed to the right and up (oculomotor synergy), he performs a smooth exhalation (respiratory synergy) and relaxes the muscles. The doctor conducts a smooth preliminary passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine to the right, and the left shoulder girdle down, until the border of passive movement with moderate pain in the patient is reached. The doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. When working on the right side of the patient’s neck, the situation is mirrored. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks to the left and up (oculomotor synergy), takes a smooth breath (respiratory synergy) and simultaneously performs a movement in the opposite direction with a force of 50% of the maximum possible, overcoming the inferior resistance of the doctor’s hands. The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle depends on the border of passive movement achieved during preliminary passive stretching or repeated passive stretching. In this case, the patient’s left ear and left shoulder joint are moving towards each other and should be as close as possible. At the same time, the doctor leans forward slightly on the patient and, using the weight of his body, performs inferior work. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed to the left and up (oculomotor synergy). The patient’s left ear and left shoulder joint are brought together. Due to the resistance of the doctor’s hands and the patient’s tension, the final phase of the movement is maintained in isometric mode with an average force of 50% of the maximum possible. In this case, the doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks to the right and up (oculomotor synergy), makes a smooth exhalation (respiratory synergy), relaxes the muscles, and at the same time the doctor moves in the opposite direction (to the right). Upon reaching the old border of passive movement, the doctor, using the weight of his body, conducts a smooth repeated passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine sideways with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor fixes the left side surface of the patient’s head with the right hand, and fixes the patient’s left shoulder joint with the left hand from above and in front. It is necessary to strive to bring the head closer to the right shoulder joint. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the end of this stage, the doctor performs 5-10 swaying movements in the direction of the performed stretching, reinforcing this effect. The duration of the stage is 8-10 seconds.

The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle in lateroflexion varies from about 15 to 90 °. The number of repeated cycles is 3-5 in one session. The impact is carried out from two sides.

III. Manipulation treatment of the upper and middle cervical spine in the extensor position of the spine and lower extremities lying down.

Receptions I and II contribute to the improvement of blood supply (an equilibrium is achieved between arterial inflow and venous, lymphatic outflow), stretching of the musculo-ligamentous apparatus of these departments and serve as preparation for subsequent safe manipulations.

Starting position: the patient lies on his back with legs straightened and slightly divorced. Five ergonomic ridges lie under his neck, lower back, upper thighs, knees and Achilles tendons. Due to the ergonomic rollers under the lower back and neck, POP and SHOP are unbent, the chin is slightly raised. Due to the ergonomic rollers under the upper thighs, knees and Achilles tendons, the lower limbs are unbent, and the intensification of pain during extension of the POP is prevented. The patient’s extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

The ergonomic roller is removed from under the neck of the patient. The doctor with his hands creates a tilt of the head back and the extensor position of the SHOP. The patient is manipulated on the upper and middle cervical spine using rotation and tracking from two sides.

The number of PDS on which manipulations can be performed depends on the stage of myofixation in which the patient is located.

IV. Post-activation stretching of the musculo-ligamentous apparatus of the cervical, upper thoracic spine and shoulder girdle with tension and vibrational displacement of the dural sac in lateral flexion in the extensor position of the spine sitting.

This technique is not recommended for use in the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when the patient's sitting position, relying on a sore buttock, aggravates the pain syndrome.

At the stage of regression of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can sit without intensifying the pain syndrome, a pose is used in the extensor position of the spine while sitting. There are two possible options for the starting position.

Starting position No. 1: the patient sits on the table with his back to the doctor, leaning forward and tilting his head back. The doctor puts one leg, bent at the knee joint, with his foot on the couch on the side and behind the patient, the patient throws his hand over the doctor’s thigh, leaning on it. Due to the support on the thigh of the doctor, located on the side and behind the patient, and the tilt of the head back, the patient’s SHOP, GOP and POP are unbent, which forms the extensor position of the spine.

Starting position No. 2: the patient sits on the table with his back to the doctor, leaning forward and tilting his head back. The patient puts one arm, straightened in the elbow joint, on the side and back of himself, leaning on it. Due to the support on his hand, located on the side and behind the patient and the tilt of the head back, the patient’s SHOP, GOP and POP are unbent, which forms the extensor position of the spine.

1. Preliminary passive stretching.

The doctor is standing on the patient’s back. If the patient rests with his right hand, then the work is done on the left half of the neck and vice versa. Work is carried out, for example, on the left half of the neck. The doctor puts his right hand on the left lateral surface of the patient’s head, the left hand - on top of his left shoulder joint. The patient's gaze is directed to the right and up (oculomotor synergy), he performs a smooth exhalation (respiratory synergy) and relaxes the muscles. The doctor conducts a smooth preliminary passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine to the right, and the left shoulder girdle down, until the border of passive movement with moderate pain in the patient is reached. The doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. When working on the right side of the patient’s neck, the situation is mirrored. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks to the left and up (oculomotor synergy), takes a smooth breath (respiratory synergy) and simultaneously performs a movement in the opposite direction with a force of 50% of the maximum possible, overcoming the inferior resistance of the doctor’s hands. The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle depends on the border of passive movement achieved during preliminary passive stretching or repeated passive stretching. In this case, the patient’s left ear and left shoulder joint are moving towards each other and should be as close as possible. At the same time, the doctor leans forward slightly on the patient and, using the weight of his body, performs inferior work. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed to the left and up (oculomotor synergy). The patient’s left ear and left shoulder joint are brought together. Due to the resistance of the doctor’s hands and the patient’s tension, the final phase of the movement is maintained in isometric mode with an average force of 50% of the maximum possible. In this case, the doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks to the right and up (oculomotor synergy), makes a smooth exhalation (respiratory synergy), relaxes the muscles, and at the same time the doctor moves in the opposite direction (to the right). Upon reaching the old border of passive movement, the doctor, using the weight of his body, conducts a smooth repeated passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine sideways with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor fixes the left side surface of the patient’s head with the right hand, and fixes the patient’s left shoulder joint with the left hand from above and in front. It is necessary to strive to bring the head closer to the right shoulder joint. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the end of this stage, the doctor performs 5-10 swaying movements in the direction of the performed stretching, reinforcing this effect. The duration of the stage is 8-10 seconds.

The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle in lateroflexion varies from about 15 to 90 °. The number of repeated cycles is 3-5 in one session. The impact is carried out from two sides.

V. Manipulation treatment of the cervicothoracic junction and cervical spine in the extensor position of the spine while sitting.

Receptions I, II and IV contribute to the improvement of blood supply (an equilibrium is achieved between arterial inflow and venous, lymphatic outflow), stretching of the musculo-ligamentous apparatus of this department and serve as preparation for subsequent safe manipulations.

Starting position: the patient sits on the table, bending his body and tilting his head back, while leaning his back on the doctor. Due to this, the SHOP, GOP and POP of the patient are unbent, which forms the extensor position of the spine.

A) The patient is performed nonspecific manipulations on the cervicothoracic junction using rotation, distraction and counter-retention in the position of the patient sitting on both sides. During the manipulations, the patient’s body is pulled up by the doctor and the extensor position of the spine is strengthened.

B) In the same initial position, the patient can perform nonspecific manipulations on the upper and middle cervical spine using rotation, distraction and counter-retention in the position of the patient sitting on both sides. During the manipulations, the patient’s body is pulled up by the doctor and the extensor position of the spine is strengthened. Manipulations on the upper and middle cervical spine in the sitting position duplicate the manipulations in the supine position, since it happens that the manipulations do not work out in one position, but go out in another.

The number of PDS on which manipulations can be performed depends on the stage of myofixation in which the patient is located.

VI. Post-activation stretching of the anterolateral group of the musculo-ligamentous apparatus of the lower leg (extensor of the foot and I finger) and ankle joint in flexion in the extensor position of the spine and lower extremities.

Starting position: the patient lies on his back with legs straightened and slightly divorced. Five ergonomic ridges lie under his neck, lower back, upper thighs, knees and Achilles tendons. Due to the ergonomic rollers under the lower back and neck, POP and SHOP are unbent, the chin is slightly raised. Due to the ergonomic rollers under the upper thighs, knees and Achilles tendons, the lower limbs are unbent, and the intensification of pain during extension of the POP is prevented. The patient’s extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s sore foot. One leg of the doctor, bent at the knee and hip joints, lies on the table with his lower leg. The patient’s straight, stretched leg rests on the thigh of the doctor’s leg with the Achilles tendon. The doctor holds the patient’s knee with one hand, the other fixes his foot. The patient’s face and gaze are directed upward towards the ceiling, he exhales (breathing synergy) and relaxes the muscles. The doctor performs a smooth preliminary passive stretching of the anterolateral group of the musculo-ligamentous apparatus of the lower leg and ankle joint, producing plantar flexion of the patient's foot until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks up to the forehead (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head slightly tilts back, and at the same time with a force of 50% of the maximum possible, he begins to gently press the foot on the doctor’s hand, making the back extension of the foot and I finger. In this case, the patient’s straight leg also smoothly presses down on the doctor’s thigh. The amplitude of the foot movement depends on the border of the passive movement achieved during the preliminary passive stretching or repeated passive stretching. At the same time, the doctor performs inferior work, resisting the hand and slightly shifting the weight of his body in the same direction. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed up to the forehead (oculomotor synergy), his head is slightly thrown back. The final phase of the back extension of the foot, I finger and muscle and ligament tension is maintained in isometric mode with a force of 50% of the maximum possible. The doctor fixes this position, resisting the hand and slightly shifting the weight of his body in the same direction. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks down to the middle position (oculomotor synergy), makes a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles, while his head returns to its original position. At the same time, the doctor performs a smooth plantar flexion of the foot. Upon reaching the initial border of passive movement, the doctor deviates slightly towards the foot and, using the weight of his body, conducts a smooth repeated passive stretching of the anterior-lateral group of the musculo-ligamentous apparatus of the lower leg and ankle joint. The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. At the end of this stage, the doctor performs 5-10 swaying movements in the same direction, enhancing the effect of stretching. The duration of the stage is 8-10 seconds.

To further raise the leg up, the position of the doctor in relation to the patient changes: his thigh moves under the middle of the patient's calf muscle. The subsequent steps of the PAR are performed as described above.

The following position: the patient lies the same way, and the doctor puts his foot in the foot on the table. The patient’s leg lies on the doctor’s thigh with an Achilles tendon. Subsequent stages of PAR are described above.

The following position: the patient lies the same way, the doctor puts his foot on the table with his foot and moves his hip under the middle of the patient's calf muscle. Subsequent stages of PAR are described above.

The amplitude of the foot in extensional flexion is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Another embodiment of stretching the anterolateral group of the musculo-ligamentous apparatus of the lower leg and ankle joint can be carried out. For this, the forearm is first used as a support for the patient’s leg, and then, with further stretching of the musculo-ligamentous apparatus, the physician’s shoulder girdle. The stages of preliminary passive stretching, isotonic and isometric activations, repeated passive stretching are performed similarly to the option described above.

VII. Post-activation stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg (flexor of the foot) and ankle joint in extensia while lying on the back in the extensor position of the spine and lower extremities.

Starting position: the patient lies on his back with legs straightened and slightly divorced. Five ergonomic ridges lie under his neck, lower back, upper thighs, knees and Achilles tendons. Due to the ergonomic rollers under the lower back and neck, POP and SHOP are unbent, the chin is slightly raised. Due to the ergonomic rollers under the upper thighs, knees and Achilles tendons, the lower limbs are unbent, and the intensification of pain during extension of the POP is prevented. The patient’s extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s sore foot. One leg of the doctor, bent at the knee and hip joints, lies on the table with his lower leg. The patient’s straight, stretched leg rests on the thigh of the doctor’s leg with the Achilles tendon. The doctor holds the patient’s hip or pelvis with one hand, and fixes his foot with the other. The patient’s face and gaze are directed upward towards the ceiling, he exhales (breathing synergy) and relaxes the muscles. The doctor performs a smooth preliminary passive stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg and ankle joint, performing back extension of the patient’s foot to the border of passive movement with moderate pain in the patient. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks up to the forehead (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head slightly tilts back and the extension of the SHOP is enhanced. Simultaneously with a force of 50% of the maximum possible, he begins to smoothly press his foot on the doctor’s hand, producing plantar flexion. In this case, the patient’s straight leg also smoothly presses down on the doctor’s thigh. The amplitude of the foot movement depends on the border of the passive movement achieved during the preliminary passive stretching or repeated passive stretching. At the same time, the doctor performs inferior work, resisting the hand and slightly shifting the weight of his body in the opposite direction. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed up to the forehead (oculomotor synergy), his head is slightly thrown back, the extension of the SHOP is enhanced. The final phase of plantar flexion of the foot and tension of muscles and ligaments is maintained in isometric mode with a force of 50% of the maximum possible. The doctor fixes this position, resisting the hand and slightly shifting the weight of his body in the opposite direction. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks down to the middle position (oculomotor synergy), makes a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles, while his head returns to its original position. At the same time, the doctor performs a smooth back extension of the foot. Upon reaching the initial border of passive movement, the doctor slightly deviates to the side and, using the weight of his body, conducts a smooth repeated passive stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg and ankle joint. The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. At the end of this stage, the doctor performs 5-10 swaying movements in the same direction, enhancing the effect of stretching. The duration of the stage is 8-10 seconds.

To further raise the leg up, the position of the doctor in relation to the patient changes: his thigh moves under the middle of the patient's calf muscle. The subsequent steps of the PAR are performed as described above.

The following position: the patient lies the same way, and the doctor puts his foot in the foot on the table. The patient’s leg lies on the doctor’s thigh with an Achilles tendon. With one hand, the doctor rests on the table, transferring body weight to it, with the other hand fixes the patient’s foot. Subsequent stages of PAR are described above.

The following position: the patient lies the same way, the doctor puts his foot on the table with his foot and moves his hip under the middle of the patient's calf muscle. Subsequent stages of PAR are described above.

The amplitude of the foot in extensional flexion is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Another embodiment of stretching the posterior group of the musculo-ligamentous apparatus of the lower leg and ankle joint can be carried out. For this, the forearm is first used as a support for the patient’s leg, and then, with further stretching of the musculo-ligamentous apparatus, the physician’s shoulder girdle. The stages of preliminary passive stretching, isotonic and isometric activations, repeated passive stretching are performed similarly to the option described above.

Viii. Post-activation stretching of the sacro-tuberous ligament, the musculo-ligamentous apparatus of the gluteal region (hip extensors) and the hip joint in flexion in the extensor position of the spine and lower extremities.

Starting position: the patient lies on his back with legs straightened and slightly divorced. Five ergonomic ridges lie under his neck, lower back, upper thighs, knees and Achilles tendons. Due to the ergonomic rollers under the lower back and neck, POP and SHOP are unbent, the chin is slightly raised. Due to the ergonomic rollers under the upper thighs, knees and Achilles tendons, the lower limbs are unbent, and the intensification of pain during extension of the POP is prevented. The patient’s extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s sore foot. The stretched leg bends at the knee and hip joints, the patient’s hands are locked into the lock and the thigh is fixed under the knee joint. The face and gaze are directed upward to the ceiling, the patient exhales (breathing synergy) and relaxes the muscles. The doctor is standing on the side and with the forearm of one hand presses on the patient's knee, bringing him closer to the chest in the direction of the shoulder of the same name. The palm of the doctor’s other hand rests on the lower third of the thigh of the patient’s lying leg, preventing her from bending. In this case, a smooth preliminary passive stretching of the sacro-tubercular ligament, the musculo-ligamentous apparatus of the gluteal region (hip extensors) and the hip joint occurs until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks up to the forehead (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head slightly tilts back and the extension of the SHOP is enhanced. At the same time, he performs a smooth movement of the knee in the direction from the shoulder of the same name, unbending the leg in the hip joint with a force of 50% of the maximum possible. The amplitude of the leg movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. In this case, the doctor leans forward slightly and, resisting with his weight, performs inferior work. The final phase of the leg movement is limited by the length of the patient's bent arms that fix his thigh. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed up to the forehead (oculomotor synergy), his head is slightly thrown back, the extension of the SHOP is enhanced. The angle between the patient’s thigh and the horizontal plane of the torso is 75-80 °. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans forward slightly and, using the weight of his body, fixes this position. The patient holds his thigh with his hands, which reduces the physical effort of the doctor. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient lowers his gaze to the middle position (oculomotor synergy), performs a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles, while his head returns to its original position. At the same time, the doctor performs a smooth movement in the patient's knee in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the sacro-tuberous ligament, the musculo-ligamentous apparatus of the gluteal region (hip extensors) and the hip joint. The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain for the patient. It is necessary to strive to put the patient's hip on the costal arch from the same side. The relaxed coupled hands of the patient retain their position under the knee joint. The doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of the hip movement in flexion-extension is 15-45 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

IX. Post-activation stretching of the posterior group of the musculo-ligamentous apparatus of the thigh, gluteal region (hip extensors), knee and hip joints in flexion, lower leg (flexor of the foot) and ankle joint in extension in the extensor position of the spine and lower extremities.

Starting position: the patient lies on his back with legs straightened and slightly divorced. Five ergonomic ridges lie under his neck, lower back, upper thighs, knees and Achilles tendons. Due to the ergonomic rollers under the lower back and neck, POP and SHOP are unbent, the chin is slightly raised. Due to the ergonomic rollers under the upper thighs, knees and Achilles tendons, the lower limbs are unbent, and the intensification of pain during extension of the POP is prevented. The patient’s extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s sore foot. The patient’s stretched leg bends in the hip and knee joints, the foot is in a state of back extension in the ankle joint and the Achilles tendon lies on the physician’s shoulder. The patient’s same hand holds on to the back of the thigh, the other lies on the table. The patient’s face and gaze are directed upward towards the ceiling, he exhales (breathing synergy) and relaxes the muscles. The doctor fixes the patient’s foot with one hand and fixes the patient’s thigh with the other hand to the table. This is necessary to prevent it from bending when stretching the developed leg. The doctor leans forward, bringing the patient's hip and knee closer to his costal arch. At the same time, it enhances the flexion of the leg in the knee and hip joints and the extension of the foot in the ankle joint. There is a smooth preliminary passive stretching of the posterior group of the musculo-ligamentous apparatus of the thigh and lower leg (extensor femur and flexor of the foot), the hip, knee and ankle joints until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks up to the forehead (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head tilts slightly and the extension of the SHOP is enhanced. At the same time, he begins to smoothly press his foot on the doctor with a force of 50% of the maximum possible, unbending it in the hip, knee joints, and performing plantar flexion of the foot in the ankle joint. It is necessary to strive for full straightening of the leg in the knee and ankle joints, while the final angle between the straight leg and the plane of the table depends on the severity of muscle tone and ligaments. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. One doctor’s hand lies on the sole of the patient’s foot, resisting it, the other presses on the knee joint, helping the patient’s leg straighten. There is a smooth tension of the ischiocrural muscle group and ligaments. In this case, the doctor leans forward slightly and, using the weight of his body, counteracts. The final phase of the leg movement is limited by the length of the patient’s bent arm of the same name, which fixes his hip. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed up to the forehead (oculomotor synergy), his head is slightly thrown back, the extension of the SHOP is enhanced. The final phase of leg straightening and plantar flexion of the foot is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans forward slightly and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks down to the middle position (oculomotor synergy), makes a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles, while his head returns to its original position. At the same time, the doctor performs a smooth movement of the patient's hip and knee in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the posterior group of the musculo-ligamentous apparatus of the thigh and lower leg (extensor femur and flexor of the foot), hip, knee and ankle joints. The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. In this case, the patient’s leg extends in the ankle and bends in the knee and hip joints. It is necessary to strive to ultimately put the front surface of his thigh on the stomach and costal arch on the same side. To enhance the stretching of the muscles and ligaments of the posterior thigh, the doctor, using the weight of his body, presses the patient's leg bent in the hip and knee joint to his stomach and costal arch. Then the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

To enhance the stretching of the muscles and ligaments of the lower leg, the doctor leans back and straightens the patient's relaxed leg to a vertical position due to pressure on the knee joint. The number of repetitions is 3-5.

In patients with well-stretched muscles and ligaments, the doctor fixes the straightened knee joint with one hand, and the heel and sole of the foot with the other hand. After that, he makes 5-10 additional tensile movements on the musculo-ligamentous apparatus of the lower leg due to the strengthening of the back extension of the foot.

The joint amplitude of the movement of the leg in flexion-extension is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

X. Post-activation stretching of the sacrospinous, sacroiliac ligaments, the musculo-ligamentous apparatus of the gluteal region (the abducting and rotating femurs) and the hip joint in adduction in the extensor position of the spine and lower extremities.

Starting position: the patient lies on his back with legs straightened and slightly divorced. Five ergonomic ridges lie under his neck, lower back, upper thighs, knees and Achilles tendons. Due to the ergonomic rollers under the lower back and neck, POP and SHOP are unbent, the chin is slightly raised. Due to the ergonomic rollers under the upper thighs, knees and Achilles tendons, the lower limbs are unbent, and the intensification of pain during extension of the POP is prevented. The patient’s extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s sore foot. The stretched leg is bent at the knee and hip joints, its eponymous brush is located in the popliteal fold, and the opposite at the foot. The patient’s other leg is bent at the knee and hip joints and lies on the table. The patient’s face and gaze are straight, he exhales (breathing synergy) and relaxes the muscles. The doctor conducts a smooth preliminary passive stretching of the sacrospinous, sacroiliac ligaments, the musculoskeletal apparatus of the gluteal region (the abducting and rotating femurs) and the hip joint until the border of passive movement with moderate pain for the patient is reached. At the same time, he brings the patient's knee to the opposite shoulder and fixes it with his forearm. The doctor fixes the foot of this leg with the brush of the other hand. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks up to the forehead (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head slightly tilts back and the extension of the SHOP is enhanced. At the same time, the patient performs a smooth movement of the knee in the direction from the opposite shoulder, deflecting the leg in the hip joint with a force of 50% of the maximum possible. The amplitude of the leg movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. The final phase of the leg movement is limited by the length of the patient's extended arms, which fixes his knee joint and foot. In this case, the doctor leans slightly forward and, using the weight of his body, exerts resistance, and also helps to correctly implement the trajectory of movement by fixing the foot. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed up to the forehead (oculomotor synergy), his head is slightly thrown back, the extension of the SHOP is enhanced. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. The angle between the patient’s hip and the horizontal plane is 75-80 °, and the lower leg and foot are rotated inward. The patient holds his knee joint and foot with his hands, which reduces the physical effort of the doctor. In this case, the doctor leans forward slightly and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient lowers his gaze to the middle position (oculomotor synergy), performs a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles, while his head returns to its original position. At the same time, the doctor performs a smooth movement in the patient's knee in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the sacro-awned, sacroiliac ligaments, musculo-ligamentous apparatus of the gluteal region (abducting and turning the hip outwards) and the hip joint. The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. The doctor tries to bring the knee of the stretched leg closer to the opposite half of the chest. Relaxed hands of the patient retain their position on the knee joint and foot. Then the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of the hip movement in adduction-abduction is 15-45 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Xi. Post-activation stretching of the lateral and posterior groups of the musculo-ligamentous apparatus of the thigh, gluteal region (abduction and extension of the thigh), hip and knee joints in adduction in the extensor position of the spine and lower extremities.

Starting position: the patient lies on his side. The lower leg, unbent in the hip joint, slightly bent at the knee joint, and the patient's body are positioned at an obtuse angle, open posteriorly. Due to the straightened underlying leg, the POP is unbent. The patient's overlying leg is bent at the hip and knee joints, her foot lies in the popliteal fossa. The head rests on an ergonomic roller and leans back, the chin is slightly raised. Due to this, SHOP and GOP are unbent, and also POP is unbent. The unbent lower leg, the unfolded POP, GOP and SHOP form the extensor position of the spine and lower extremities.

1. Preliminary passive stretching.

The patient’s stretched (overlying) leg, bent at the hip and knee joints, lowers and is located outside the table, while the foot rests on the doctor’s thigh with the Achilles tendon. The far arm of the patient is held by the edge of the table, and the near arm rests on top of the thigh of the stretched leg. The patient’s face and gaze are straight, he exhales (breathing synergy) and relaxes the muscles. The doctor fixes the patient’s knee with one hand and fixes the patient’s thigh with the other hand to the table. This is necessary to prevent it from bending when stretching the stretched leg. The doctor moves sideways and brings the inner surface of the patient's thigh and knee closer to the edge of the table. At the same time, it enhances the flexion of the leg in the knee and hip joints. A smooth preliminary passive stretching of the lateral and posterior groups of the musculo-ligamentous apparatus of the thigh (abduction and extension of the thigh), hip and knee joints occurs until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks up to the forehead (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head tilts slightly and the extension of the SHOP is enhanced. At the same time, he begins to smoothly press his foot on the doctor with a force of 50% of the maximum possible, unbending it in the hip and knee joints. It is necessary to strive for full straightening of the leg in the knee joint, while the final angle between the stretched and healthy leg depends on the severity of muscle tone and ligaments. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. One doctor’s hand lies on the thigh of the patient’s healthy leg, preventing her from bending, the other presses on the knee joint of the stretched leg, helping her to straighten. There is a smooth tension of the abducent and ischiocrural muscle groups and ligaments. In this case, the doctor leans slightly to the side and, using the weight of his body, provides resistance. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed up to the forehead (oculomotor synergy), his head is slightly thrown back, the extension of the SHOP is enhanced. The final phase of leg straightening is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans slightly to the side and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks down to the middle position (oculomotor synergy), makes a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles, while his head returns to its original position. At the same time, the doctor performs a smooth movement of the patient’s hip and knee in the opposite direction, during which the patient’s leg bends at the knee and hip joints. Upon reaching the initial border of passive movement, the doctor leans slightly to the side and, using the weight of his body, performs a smooth repeated passive stretching of the lateral and posterior groups of the musculo-ligamentous apparatus of the thigh (abduction and extension of the thigh), hip and knee joints. The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. Ultimately, one must strive to bring the inner surface of the patient's thigh and knee closer to the edge of the table. Then the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The joint amplitude of leg movement in adduction-abduction and flexion-extension is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

XII. Post-activation stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg (flexor of the foot) and ankle joint in extensia while lying on the stomach in the extensor position of the spine and lower extremities.

Starting position: the patient lies on his stomach with legs straightened and slightly divorced. The chin is on the hands crossed in front of it, and under the ankle joints lies an ergonomic roller. The loin and neck bend down, POP and SHOP are unbent, legs are also slightly unbent. Extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

1. Preliminary passive stretching.

The patient’s stretched leg bends at the knee joint, and the hip lies on the table. The doctor holds the patient’s hip or pelvis with one hand, and fixes his foot with the other. The patient's face and gaze are directed downward, he makes a smooth exhalation (respiratory synergy) and relaxes the muscles. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The doctor performs a smooth preliminary passive stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg and ankle joint, performing back extension of the patient’s foot to the border of passive movement with moderate pain in the patient. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks up (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head rises smoothly, and his face is directed forward. SHOP and GOP are unbent to an angle of 40-45 ° due to the tension of the extensor muscles of the spine. In this case, the dural sac is stretched and displaced in the epidural space to the posterior wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the same time, the patient with a force of 50% of the maximum possible begins to smoothly press his foot on the doctor’s hand, producing plantar flexion. The amplitude of the foot movement depends on the border of the passive movement achieved during the preliminary passive stretching or repeated passive stretching. At the same time, the doctor performs inferior work, resisting the hand and slightly shifting the weight of his body in the opposite direction. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed upward (oculomotor synergy), his head is raised, his face is directed forward. The reinforced extensor position of the spine is maintained. SHOP and GOP are bent to an angle of 40-45 ° and are held due to the tension of the extensor muscles of the spine. In this case, the dural sac is stretched and located near the posterior wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. The final phase of plantar flexion of the foot and tension of muscles and ligaments is maintained in isometric mode with a force of 50% of the maximum possible. The doctor fixes this position, resisting the hand and slightly shifting the weight of his body in this direction. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks down (oculomotor synergy), performs a smooth exhalation (respiratory synergy), smoothly relaxes the muscles, lowers the cervical and thoracic spine, the head rests on the hands. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. At the same time, the doctor performs a smooth back extension of the foot. Upon reaching the initial border of passive movement, the doctor leans slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg and ankle joint. The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. At the end of this stage, the doctor performs 5-10 swaying movements in the same direction, enhancing the effect of stretching. The duration of the stage is 8-10 seconds.

The amplitude of the foot in flexion-extension is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Xiii. Post-activation stretching of the piriform muscles and musculo-ligamentous apparatus of the gluteal regions (the hips that rotate and diverts outwards), the hip, knee joints in abduction in the extensor position of the spine and lower extremities.

Starting position: the patient lies on his stomach with legs straightened and slightly divorced. The chin is on the hands crossed in front of it, and under the ankle joints lies an ergonomic roller. The loin and neck bend down, POP and SHOP are unbent, legs are also slightly unbent. Extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

1. Preliminary passive stretching.

The patient's legs are bent at the knee joints at a right angle. The doctor sits on the table, fixing with his hands the internal ankles of the patient. The patient's gaze is directed down to the table, he makes a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The doctor conducts a smooth preliminary passive stretching of the piriform muscles and musculo-ligamentous apparatus of the gluteal regions (hips and knuckles), extending the hips and knees, spreading the legs and feet outward to reach the border of passive movement with moderate pain in the patient. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks up (oculomotor synergy), takes a smooth breath (respiratory synergy), while his head rises smoothly, and his face is directed forward. SHOP and GOP are unbent to an angle of 40-45 ° due to the tension of the extensor muscles of the spine. In this case, the dural sac is stretched and displaced in the epidural space to the posterior wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the same time, the patient performs a smooth movement with a force of 50% of the maximum possible to reduce the legs and feet to each other. The amplitude of the legs depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. In this case, the doctor leans forward slightly and, using the weight of his body, performs inferior work. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed upward (oculomotor synergy), his head is raised, his face is directed forward. The reinforced extensor position of the spine is maintained. SHOP and GOP are bent to an angle of 40-45 ° and are held due to the tension of the extensor muscles of the spine. In this case, the dural sac is stretched and located near the posterior wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. The legs are bent at the knees at a right angle, the knees are closed, the legs and feet are close to each other. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks down (oculomotor synergy), performs a smooth exhalation (respiratory synergy), smoothly relaxes the muscles, lowers the cervical and thoracic spine, the head rests on the hands. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. At the same time, the doctor performs a smooth movement of his lower legs in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the piriform muscles and musculo-ligamentous apparatus of the gluteal regions (abducting and rotating the hip outward), hip and knee joints with a force of 50% of the maximum possible to a new border of passive movement with moderate pain in the patient. It is necessary to strive to bring the feet closer to the table. Then the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of motion of both legs in abduction-adduction is approximately 15-50 °. The number of repeated cycles is 3-5 in one session. The impact is performed simultaneously on both legs.

Xiv. Pressure myofascial trigger points in the extensor position of the spine and lower extremities.

Starting position: the patient lies on his stomach with legs straightened and slightly divorced. The chin is on the hands crossed in front of it, and under the ankle joints lies an ergonomic roller. The loin and neck bend down, POP and SHOP are unbent, legs are also slightly unbent. Extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

The doctor palpation determines myofascial trigger points (MPTP). Most often they are located on the back surface of the lower leg, in the gluteal region and paravertebral muscles near the affected PDS. There may be other localizations of MPTP, in particular on the posterior surface of the thigh. The bent finger in the first interphalangeal joint III finger slowly begin to exert pressure on the trigger zone. The pressure intensity within 1 minute should increase to 10-15 kg. It is necessary to choose the direction of pressure in the direction of solid tissue (bone, ligament, fascia), avoiding direction in the direction of large vessels and nerves. The duration of the procedure is 3-5 minutes. The pressure of the revealed gluteal MPTP is carried out by the elbow.

Xv. Post-activation stretching of the musculo-ligamentous apparatus of the thoracic, lumbar spine, pelvis, ileo-lumbar ligament with tension and vibrational displacement of the dural sac in rotation in the extensor position of the spine and lower extremities.

Starting position: the patient lies on a sick (let's say - left) side. The lower leg, unbent in the hip joint, slightly bent at the knee joint, and the patient's body are positioned at an obtuse angle, open posteriorly. Due to the straightened underlying leg, the POP is unbent. The patient's overlying leg is bent at the hip and knee joints, her foot lies in the popliteal fossa. The head rests on an ergonomic roller and leans back, the chin is slightly raised. Due to this, SHOP and GOP are unbent, and also POP is unbent. The unbent lower leg, the unfolded POP, GOP and SHOP form the extensor position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the back of the patient. The patient's body is deployed towards the doctor, while the face and chest are directed to the ceiling. The hand nearest to the doctor is bent at the elbow and set aside, and the far hand rests with the palm on the stomach. The doctor fixes the elbow of the near hand with his hand, bringing it closer to the table. A wrist or fist of the doctor’s other hand fixes the patient’s knee joint from above and also brings it closer to the table. The patient looks to the right and up (oculomotor synergy), makes a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles. The doctor performs a smooth preliminary passive stretching of the right half of the muscular-ligamentous apparatus of the thoracic, lumbar spine, pelvis and ileo-lumbar ligament in rotation with extension of the POP until the border of passive movement with moderate pain in the patient is reached. In this case, the doctor enhances the turn of the patient's body, bringing his near elbow and knee of the overlying leg to the table. The spine takes the form of the letter S with the left concave side of the deformity in the lumbar and thoracic spine. In this case, the dural sac is stretched and displaced in the epidural space to the left side wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks away from the doctor - to the left and up (oculomotor synergy), takes a smooth breath (respiratory synergy) and at the same time carries out a smooth rotational movement with the body and leg with a force of 50% of the maximum possible. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. The chest and head rotate from the doctor; overlying leg and pelvis - to the doctor, resting on the foot. In the final phase of the movement, the patient’s face and chest are deployed from the doctor, and the pelvis and knee to the doctor, with the knee pointing to the ceiling. POP is in a state of extension with the formation of lumbar lordosis. This is helped by the patient’s near arm, which is wrapped behind her back and her hand rests on POP. Her elbow is fixed with the hand of one doctor’s hand, and the knee rests on the straightened other hand of the doctor, the foot rests on the table and the doctor’s fist standing on the table. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. At the same time, the doctor leans forward slightly and, using the weight of his body, performs inferior work. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed away from the doctor - to the left (oculomotor synergy). The doctor leans forward slightly and, using his weight, fixes the final phase of the patient's rotational movement in isometric mode with a force of 50% of the maximum possible. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks to the right and up (oculomotor synergy), performs a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles, while the doctor rotates the patient's body in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the musculo-ligamentous apparatus of the thoracic, lumbar spine, pelvis and ileo-lumbar ligament in rotation with extension of POP. The impact is carried out with a force of 50% of the maximum possible, achieving a new border for passive movement with moderate pain in the patient. Fixation of the patient’s near arm in the EPP is terminated, and the elbow is moved to the side, fixation of the arm farthest to the doctor on the stomach is maintained. In this case, it is necessary to strive so that the knee of the overlying leg and the elbow of the hands closest to the doctor are pressed against the table. The spine takes the form of the letter S with the left concave side of the deformity in the lumbar and thoracic spine. In this case, the dural sac is stretched and displaced in the epidural space to the left side wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space.

At the end of this stage, the doctor performs 5-10 swaying movements in the same direction, enhancing the effect of stretching. The duration of the stage is 8-10 seconds.

The joint amplitude of the GOP, POP, pelvis movement in rotation with POP extension is 15-90 °. The number of repeated cycles is 3-5 in one session. The exposure is performed first on the healthy and then on the diseased half of the spine with a stronger stretch on the diseased side. In the presence of analgesic scoliosis, the effect is performed on only one side - on the concave side of the deformation. At the end of the procedure, the patient is put on a rubber retainer on the shin of the overlying leg, and a sports weighting agent weighing 3-5 kg is placed on top of her thigh. The patient is given the overlying arm to the side and upward at an angle of 45 °, he relaxes and breathes calmly for 3-5 minutes. This exposure element greatly enhances the tensile effect.

Xvi. Mobilization of the sacroiliac joints of the pelvis in the extensor position of the spine and lower extremities.

A) Mobilization of blocked CPS in the patient’s position on the abdomen.

Starting position: the patient lies on his stomach with legs straightened and slightly divorced. The chin is on the hands crossed in front of it, and under the ankle joints lies an ergonomic roller. The loin and neck bend down, POP and SHOP are unbent, legs are also slightly unbent. Extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

The doctor mobilizes the blocked KPS according to V. Schneider and (or) according to A. Stoddart.

B) It is also possible to carry out the mobilization of the blocked CPS in the position of the patient on the back.

Starting position: the patient lies on his back with legs straightened and slightly divorced. Five ergonomic ridges lie under his neck, lower back, upper thighs, knees and Achilles tendons. Due to the ergonomic rollers under the lower back and neck, POP and SHOP are unbent, the chin is slightly raised. Due to the ergonomic rollers under the upper thighs, knees and Achilles tendons, the lower limbs are unbent, and the intensification of pain during extension of the POP is prevented. The patient’s extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

The doctor mobilizes the blocked CPS using the patient’s bent, injured leg as a lever.

C) It is also possible to carry out the mobilization of the blocked CPS in the position of the patient lying on his side.

Starting position: the patient lies on his side. The lower leg, unbent in the hip joint, slightly bent at the knee joint, and the patient's body are positioned at an obtuse angle, open posteriorly. Due to the straightened underlying leg, the POP is unbent. The patient's overlying leg is bent at the hip and knee joints, her foot lies in the popliteal fossa. The head rests on an ergonomic roller and leans back, the chin is slightly raised. Due to this, SHOP and GOP are unbent, and also POP is unbent. The unbent lower leg, the unfolded POP, GOP and SHOP form the extensor position of the spine and lower extremities.

The doctor mobilizes the blocked KPS using the overlying iliac wing as a lever.

Sometimes mobilization ends with manipulation. Receptions are repeated 10-30 times.

Xvii. Manipulation treatment of the thoracic spine in the extensor position of the spine and lower extremities.

Reception XV helps to improve blood supply (an equilibrium is achieved between the arterial inflow and venous, lymphatic outflow), stretching the muscular-ligamentous apparatus of the HOP and serves as a preparation for subsequent safe manipulations.

Starting position: the patient lies on his stomach with legs straightened and slightly divorced. The chin is on the hands crossed in front of it, and under the ankle joints lies an ergonomic roller. The loin and neck bend down, POP and SHOP are unbent, legs are also slightly unbent. Extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

The patient turns his head on his side, stretches his arms along the body, puts his hands under the anterior inner thighs. The patient is performed GOP manipulations using rotation and short levers.

Xviii. Mobilization of the skin of the lumbar spine in the extensor position of the spine and lower extremities.

Starting position: the patient lies on his stomach with legs straightened and slightly divorced. The chin is on the hands crossed in front of it, and under the ankle joints lies an ergonomic roller. The loin and neck bend down, POP and SHOP are unbent, legs are also slightly unbent. Extended and divorced legs, extended POP and SHOP form the extensor position of the spine and lower extremities.

The doctor palpation forms a fold of the skin and performs its displacement above the spinous processes of the upper sacral, lumbar and lower thoracic vertebrae. In this case, the skin stretches with a characteristic sound phenomenon in the form of a click. Reception is repeated 3 times.

XIX. Manipulation treatment of the lumbar spine in the extensor position of the spine and lower extremities.

By the end of the course of treatment, POP contracture is eliminated, and it becomes possible to use POP manipulations. Receptions XV and XVIII help to improve blood supply (a balance is achieved between arterial inflow and venous, lymphatic outflow), stretching of the musculo-ligamentous apparatus, skin POP and serve as a preparation for subsequent safe manipulations.

Starting position: the patient lies on a sick (let's say left) side. The lower leg, unbent in the hip joint, slightly bent at the knee joint, and the patient’s body are placed at an obtuse angle open posteriorly. Due to the straightened underlying leg, the POP is unbent. The patient's overlying leg is bent at the hip and knee joints, her foot lies in the popliteal fossa. The head rests on an ergonomic roller and leans back, the chin is slightly raised. Due to this, SHOP and GOP are unbent, and also POP is unbent. The unbent lower leg, the unfolded POP, GOP and SHOP form the extensor position of the spine and lower extremities.

The patient is manipulated on healthy lumbar PDS on both sides using rotation and extension. Manipulation of POP is performed provided that the hernias of MPD POP without sequestration and their size is not more than 1 cm in depth.

If a combination of extravertebral syndromes, anatomically associated with both the lumbar and sacral plexuses, is detected, it is performed:

I. Post-activation stretching of the musculo-ligamentous apparatus of the cervical, upper thoracic spine and shoulders with tension and vibrational displacement of the dural sac in rotation in the neutral position of the spine and lower extremities.

Starting position: the patient lies on his back. Under the knees are three ergonomic cushions folded in a pyramid. The patient's legs are bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral (half-bent and divorced) position of the legs and a neutral (not bending, not bending) POP position are created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the side of the patient’s head. Work is carried out, for example, on the left half of the neck. The doctor puts his right hand on the left side surface of the patient's face, the left - on the left shoulder joint in front and top. The patient's gaze is directed to the right (oculomotor synergy), he makes a smooth exhalation (respiratory synergy) and relaxes the muscles. The doctor turns his head to the right, and the left shoulder joint stretches back and down. The doctor conducts a smooth preliminary passive stretching of the musculo-ligamentous apparatus of the left half of the cervical, upper thoracic spine and left shoulder girdle until the border of passive movement with moderate pain in the patient is reached. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space.

When working on the right side of the patient’s neck, the situation is mirrored. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks to the left side (oculomotor synergy), takes a smooth breath (respiratory synergy) and at the same time rotates the head in the same direction with a force of 50% of the maximum possible with overcoming the inferior resistance of the right hand of the doctor. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. The rotation is made to a position in which the patient's face is facing up. At the same time, the doctor leans back slightly and, using the weight of his body, performs inferior work. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed to the left side (oculomotor synergy). The face is facing up. Due to the resistance of the doctor’s hands and the patient’s tension, the final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor slightly deviates back and, using the weight of his body, fixes this position. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks to the right side (oculomotor synergy), exhales smoothly (breathing synergy), relaxes the muscles, and at the same time the doctor moves the patient's head and neck to the right. Upon reaching the initial border of passive movement, the doctor performs a smooth repeated passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine (spinal rotators) in rotation with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor fixes the left side surface of the patient’s head with the right hand and the left shoulder joint in front of the patient with the left hand and leans forward slightly using his body weight, stretching the patient’s neck and shoulder girdle. It is necessary to strive for maximum rotation of the head, cervical and upper thoracic spine to the right. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the end of this stage, the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The joint amplitude of movement of the cervical, upper thoracic spine and shoulders in rotation in the neutral position of the spine ranges from about 15 to 90 °. The number of repeated cycles is 3-5 in one session. The impact is carried out from two sides.

II. Post-activation stretching of the musculo-ligamentous apparatus of the cervical, upper thoracic spine and shoulder girdle with tension and vibrational displacement of the dural sac in lateroflexion in the neutral position of the spine and lower extremities lying down.

Starting position: the patient lies on his back. Under the knees are three ergonomic cushions folded in a pyramid. The patient's legs are bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral (half-bent and divorced) position of the legs and a neutral (not bending, not bending) POP position are created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the side of the patient’s head. Work is carried out, for example, on the left half of the neck. The doctor puts his right hand on the left lateral surface of the patient’s head, the left hand - on top of his left shoulder joint. The patient's gaze is directed to the right (oculomotor synergy), he performs a smooth exhalation (respiratory synergy) and relaxes the muscles. The doctor conducts a smooth preliminary passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine to the right, and the left shoulder girdle down, until the border of passive movement with moderate pain in the patient is reached. The doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. When working on the right side of the patient’s neck, the situation is mirrored. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks to the left (oculomotor synergy), takes a smooth breath (respiratory synergy) and simultaneously performs a movement in the opposite direction with a force of 50% of the maximum possible, overcoming the inferior resistance of the doctor’s hands. The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle depends on the border of passive movement achieved during preliminary passive stretching or repeated passive stretching. In this case, the patient’s left ear and left shoulder joint are moving towards each other and should be as close as possible. At the same time, the doctor leans forward slightly on the patient and, using the weight of his body, performs inferior work. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed to the left (oculomotor synergy). The patient’s left ear and left shoulder joint are brought together. Due to the resistance of the doctor’s hands and the patient’s tension, the final phase of the movement is maintained in isometric mode with an average force of 50% of the maximum possible. In this case, the doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks to the right (oculomotor synergy), makes a smooth exhalation (respiratory synergy), relaxes the muscles, and at the same time the doctor moves in the opposite direction (to the right). Upon reaching the old border of passive movement, the doctor, using the weight of his body, conducts a smooth repeated passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine sideways with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor fixes the left side surface of the patient’s head with the right hand, and fixes the patient’s left shoulder joint with the left hand from above and in front. It is necessary to strive to bring the head closer to the right shoulder joint. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the end of this stage, the doctor performs 5-10 swaying movements in the direction of the performed stretching, reinforcing this effect. The duration of the stage is 8-10 seconds.

The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle in lateroflexion varies from about 15 to 90 °. The number of repeated cycles is 3-5 in one session. The impact is carried out from two sides.

III. Manipulation treatment of the upper and middle cervical spine in a neutral position of the spine and lower limbs lying down.

Receptions I and II contribute to improving blood supply to the spine (an equilibrium is achieved between the arterial inflow and venous, lymphatic outflow), stretching the muscular-ligamentous apparatus of these departments and serve as a preparation for subsequent safe manipulations.

Starting position: the patient lies on his back. Under the knees are three ergonomic cushions folded in a pyramid. The patient's legs are bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral (half-bent and divorced) position of the legs and a neutral (not bending, not bending) POP position are created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

The ergonomic pillow is removed from under the head and neck. The doctor with his hands creates a neutral (not flexion, not extension) position of the SHOP. The patient is manipulated on the upper and middle cervical spine using rotation and tracking from two sides.

The number of PDS on which manipulations can be performed depends on the stage of myofixation in which the patient is located.

IV. Post-activation tension of the musculo-ligamentous apparatus of the cervical, upper thoracic spine and shoulder girdle with tension and vibrational displacement of the dural sac in lateroflexion in the neutral position of the spine sitting.

This technique is not recommended for use in the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the lumbar intervertebral discs, when the patient’s sitting position, resting on a sore buttock, intensifies the pain syndrome.

In the regression stage of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can sit without intensifying the pain syndrome, a pose in a neutral sitting position of the spine is used. There are two possible options for the starting position.

Starting position No. 1: the patient sits on the table with his back to the doctor in a neutral position (not flexion, not extension), chin in a neutral position (not lowered, not raised). The doctor puts one leg, bent at the knee joint, with his foot on the couch on the side of the patient, the patient throws his hand over the doctor’s thigh, leaning on it. Due to the support on the thigh of the doctor, located on the side of the patient, and the neutral position of the head and chin, the body is in a neutral position. The neutral position of the patient's SHOP, GOP and POP forms the neutral position of the spine.

Starting position No. 2: the patient sits on the table with his back to the doctor in a neutral position (not flexion, not extension), chin in a neutral position (not lowered, not raised). The patient puts one hand, straightened in the elbow joint, on the side of himself, leaning on it. Due to the support on their hand, located on the side of the patient and the neutral position of the head and chin, SHOP, GOP and POP are in a neutral position. The neutral position of the patient's SHOP, GOP and POP forms the neutral position of the spine.

1. Preliminary passive stretching.

The doctor is standing on the patient’s back. If the patient rests with his right hand, then the work is done on the left half of the neck and vice versa. Work is carried out, for example, on the left half of the neck. The doctor puts his right hand on the left lateral surface of the patient’s head, the left hand - on top of his left shoulder joint. The patient's gaze is directed to the right (oculomotor synergy), he performs a smooth exhalation (respiratory synergy) and relaxes the muscles. The doctor conducts a smooth preliminary passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine to the right, and the left shoulder girdle down, until the border of passive movement with moderate pain in the patient is reached. The doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. When working on the right side of the patient’s neck, the situation is mirrored. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks to the left (oculomotor synergy), takes a smooth breath (respiratory synergy) and simultaneously performs a movement in the opposite direction with a force of 50% of the maximum possible, overcoming the inferior resistance of the doctor’s hands. The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle depends on the border of passive movement achieved during preliminary passive stretching or repeated passive stretching. In this case, the patient’s left ear and left shoulder joint are moving towards each other and should be as close as possible. At the same time, the doctor leans forward slightly on the patient and, using the weight of his body, performs inferior work. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed to the left (oculomotor synergy). The patient’s left ear and left shoulder joint are brought together. Due to the resistance of the doctor’s hands and the patient’s tension, the final phase of the movement is maintained in isometric mode with an average force of 50% of the maximum possible. In this case, the doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks to the right (oculomotor synergy), makes a smooth exhalation (respiratory synergy), relaxes the muscles, and at the same time the doctor moves in the opposite direction (to the right). Upon reaching the old border of passive movement, the doctor, using the weight of his body, conducts a smooth repeated passive stretching of the musculo-ligamentous apparatus of the cervical and upper thoracic spine sideways with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor fixes the left side surface of the patient’s head with the right hand, and fixes the patient’s left shoulder joint with the left hand from above and in front. It is necessary to strive to bring the head closer to the right shoulder joint. In this case, the dural sac is stretched and displaced in the epidural space to the right side wall of the spinal canal (the concave side of the spine) with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. At the end of this stage, the doctor performs 5-10 swaying movements in the direction of the performed stretching, reinforcing this effect. The duration of the stage is 8-10 seconds.

The joint amplitude of movement of the cervical, upper thoracic spine and shoulder girdle in lateroflexion varies from about 15 to 90 °. The number of repeated cycles is 3-5 in one session. The impact is carried out from two sides.

V. Manipulation treatment of the cervicothoracic junction and cervical spine in a neutral sitting position.

Reception I, II and IV contribute to the improvement of blood supply (an equilibrium is achieved between arterial inflow and venous, lymphatic outflow), stretching of the musculo-ligamentous apparatus of this department and serve as preparation for subsequent safe manipulations.

Starting position: the patient sits on the table, leaning his back on the doctor, while the patient’s torso and head are in a neutral position (not flexion, not extension). The neutral position of the patient's SHOP, GOP and POP forms the neutral position of the spine.

A) The patient is performed nonspecific manipulations on the cervicothoracic junction using rotation, distraction and counter-retention in the position of the patient sitting on both sides. During the execution of the manipulations, the neutral position of the patient's body is maintained.

B) In the same initial position, the patient can perform nonspecific manipulations on the upper and middle cervical spine using rotation, distraction and counter-retention in the position of the patient sitting on both sides. Manipulations on the upper and middle cervical spine in the sitting position duplicate the manipulations in the supine position, since it happens that the manipulations do not work out in one position, but go out in another.

The number of PDS on which manipulations can be performed depends on the stage of myofixation in which the patient is located.

VI. Post-activation stretching of the inner group of the musculo-ligamentous apparatus of the thighs (adductor muscles) and hip joints in abduction in the neutral position of the spine and lower extremities.

Starting position: the patient lies on his back. The patient’s legs are bent at the knee and hip joints, the knees and feet are slightly apart, the feet are on the table and fixed with rubber clips. Due to this, a neutral (half-bent and divorced) position of the legs and a neutral (not bending, not bending) POP position are created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor sits astride the table, facing the patient’s legs. The doctor’s hands are located on the inner surface of the patient’s knees. The patient’s hands are on the inner surface of both thighs. The patient’s face and gaze are directed upward towards the ceiling, he exhales (breathing synergy) and relaxes the muscles. The doctor leans forward slightly and with both hands spreads the patient's knees, bringing his hips closer to the table (abduction - abduction). The doctor conducts a smooth preliminary passive stretching of the inner group of the musculo-ligamentous apparatus of the thighs and hip joints (adductor muscles) until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient leaves his gaze directed upward at the ceiling, takes a smooth breath (breathing synergy), while his head remains in place. At the same time, the patient performs movement in the hip joints (adduction - adduction), bringing the knees closer to each other with a force of 50% of the maximum possible. The amplitude of the movement depends on the boundary of the passive movement achieved during the preliminary passive extension or repeated passive extension. In this case, the doctor leans forward slightly and, using the weight of his body, exerts resistance. The patient's hands resist the approaching hips, which reduces the physical effort of the doctor. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed upward at the ceiling, his head remains in place. Patient's knees are close to each other. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans forward slightly and, using the weight of his body, fixes this position with his hands. At the same time, the patient holds his hips with his hands, which reduces the physical effort of the doctor. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient leaves his gaze directed upward at the ceiling, performs a smooth exhalation (breathing synergy) and relaxes the muscles, while his head remains in place. At the same time, the doctor moves the patient's knees in the opposite direction (abduction - abduction). Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the internal group of the musculo-ligamentous apparatus of the thighs and hip joints (adductors). The impact is carried out with a force of 50% from the maximum possible to a new border of movement with moderate pain in the patient. It is necessary to strive to bring the patient's hips as close as possible to the table. The relaxed hands of the patient retain their position on the inner surface of the thighs. The doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of the movement of the hips in abduction-adduction is 15-70 °. The number of repeated cycles is 3-5 in one session. The impact is performed simultaneously on both legs.

VII. Post-activation stretching of the iliopsoas muscle, the anterior group of the musculo-ligamentous apparatus of the thigh (hip flexors) and the hip joint in extension in the neutral position of the spine and lower extremities.

Starting position: the patient lies on his back, the pelvis at the level of the sciatic tubercles is on the edge of the table. The patient's legs are bent at the hip and knee joints, fixed by the hands on the knees, slightly spread apart, not pressed to the stomach. Due to bent and divorced legs, POP is smoothed out and its neutral (not bending, not bending) position is created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. The patient's bent and slightly divorced legs, the neutral position of POP, GOP and SHOP form a neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s legs. A healthy leg remains bent at the hip and knee joints. The patient’s brush of the same name is located on the lower third of the thigh near the knee, and the opposite brush on the foot of a healthy leg. The patient’s diseased leg, starting from the gluteal fold, hangs and is located outside the table. It is unbent at the hip and bent at the knee joints. One hand of the doctor rests his elbow (transferring the weight of the upper part of the body) to the knee joint from the lower leg of the patient’s healthy bent leg, the other hand with his palm or fist rests just above the knee joint from the hip side of the patient’s sore leg. The patient’s face and gaze are directed upward, he exhales (breathing synergy) and relaxes the muscles. The doctor presses a hand on a sore leg, moving it down and simultaneously fixing the knee of a healthy leg. At the same time, the doctor conducts a smooth preliminary passive stretching of the ileo-lumbar muscle, muscular-ligamentous apparatus of the anterior thigh and hip joint (hip flexors) of the sore leg until the patient reaches the border of passive movement with moderate pain. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient leaves his gaze directed upward at the ceiling, takes a smooth breath (breathing synergy), while his head remains in place. At the same time, he begins to press with an unbent thigh against the fixing palm or fist of a doctor with a force of 50% of the maximum possible, bending it in the hip joint. One doctor’s hand lies on the knee joint from the side of the patient’s thigh, giving him inferior resistance, the other presses with his elbow on the knee joint from the lower leg, fixing the bent leg. There is tension and contraction of the musculo-ligamentous apparatus of the iliopsoas muscle, the anterior surface of the thigh (hip flexors) and the hip flexion in the hip joint to the stop in the counter foot. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. At the same time, the doctor leans forward slightly and, using the weight of his body, counteracts. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed upward at the ceiling, his head remains in place. The final phase of hip flexion is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans forward slightly and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient leaves his gaze directed upward at the ceiling, performs a smooth exhalation (breathing synergy), and relaxes the muscles, while his head remains in place. At the same time, the doctor moves the patient's hips down in the opposite direction. Upon reaching the old border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the ileo-lumbar muscle, the anterior group of the musculo-ligamentous apparatus of the thigh and hip joint (hip flexors). The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. The doctor is trying to bring the hip of the stretched leg closer to the floor. Then the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of the femur in extensional flexion is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Viii. Post-activation stretching of the anterior group of the musculo-ligamentous apparatus of the thigh, lower leg (hip flexors, extensors of the lower leg and foot), knee and ankle joints in flexion in the neutral position of the spine and lower extremities.

This technique cannot be used at the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, since due to the flexion component in the neutral myofixation of the lower limb and spine, patients cannot lie on their stomach.

At the stage of regression of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can lie on their stomachs, the laying option with the neutral position of the spine and lower extremities is used.

Starting position: the patient lies on his stomach, his legs lie on the table. The forehead is on the hands crossed in front of it, the chin is in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. An ergonomic pillow lies under the patient’s stomach and pelvis. Due to this, the lowering of the lower back is eliminated and a neutral (not bending, not bending) position of the POP is created. Under the ankle joints lies an ergonomic roller, the legs are slightly bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral position of the legs is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The patient’s patient’s leg bends at a 90 ° angle in the knee joint, and the foot is in a state of plantar flexion. The patient’s face and gaze are directed down to the table; he exhales smoothly (breathing synergy) and relaxes the muscles. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The doctor fixes the patient’s foot lift with one hand, puts the other hand on the wrist joint of the working hand and performs a smooth preliminary passive stretching of the anterior group of the musculo-ligamentous apparatus of the thigh, lower leg, knee and ankle joints (hip flexors, extensors of the lower leg and foot) of the affected leg. In this case, the doctor brings the heel of the affected leg closer to the buttock until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient leaves his gaze directed down at the table, takes a smooth breath (respiratory synergy), while his head remains in place. At the same time, the patient performs leg extension in the ankle and knee joints with a force of 50% from the maximum possible to an angle of 75-80 ° (between the thigh and lower leg, between the lower leg and foot). In this case, the doctor leans forward slightly and, using the weight of his body, performs inferior work. The amplitude of the leg movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed down to the table, his head is lowered forehead to the hands crossed in front of him, his face is turned down. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. The angle of 75-80 ° between the lower leg and thigh, lower leg and foot of the patient allows the doctor to effectively use his body weight for resistance and spend less energy. In this case, the doctor leans forward slightly and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient leaves his gaze directed downward on the table, makes a smooth exhalation (respiratory synergy), relaxes the muscles, the forehead rests on the crossed hands in front of him. At the same time, the doctor moves the patient's foot and lower leg in the opposite direction to his buttock. Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the anterior group of the musculo-ligamentous apparatus of the thigh, lower leg, knee and ankle joints (hip flexors, extensors of the lower leg and foot) of the sore leg. Stretching is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. To do this, the doctor seeks to perform plantar flexion of the foot and put the heel on the patient’s buttock. After that, to increase the effectiveness of stretching, the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of movement of the lower leg and foot in flexion-extension is approximately 15-45 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

IX. Post-activation stretching of the piriform, external obturator muscles and the musculo-ligamentous apparatus of the gluteal regions (the hips that rotate and divert outside), the hip, knee joints in abduction in the neutral position of the spine and lower extremities.

This technique cannot be used at the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, because due to the pronounced flexion component in the neutral myofixation of the lower limb and spine, patients cannot lie on their stomach.

At the stage of regression of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can lie on their stomachs, the laying option with the neutral position of the spine and lower extremities is used.

Starting position: the patient lies on his stomach, his legs lie on the table. The forehead is on the hands crossed in front of it, the chin is in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. An ergonomic pillow lies under the patient’s stomach and pelvis. Due to this, the lowering of the lower back is eliminated and a neutral (not bending, not bending) position of the POP is created. Under the ankle joints lies an ergonomic roller, the legs are slightly bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral (slightly bent and divorced) position of the legs is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The patient's legs are bent at the knee joints at a right angle. The doctor sits on the table, fixing with his hands the internal ankles of the patient. The patient's gaze is directed down to the table, he makes a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The doctor conducts a smooth preliminary passive stretching of the piriform, external obturator muscles and the musculo-ligamentous apparatus of the gluteal regions (the hips that rotate and diverts outwards), the hips and knees, spreading the legs and feet outward to reach the border of passive movement with moderate pain in the patient. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient leaves his gaze directed down at the table, takes a smooth breath (respiratory synergy), while his head remains in place. At the same time, the patient performs a movement with a force of 50% of the maximum possible to reduce the legs and feet to each other. The amplitude of the legs depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. In this case, the doctor leans forward slightly and, using the weight of his body, performs inferior work. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed down to the table, his head is lowered forehead to the hands crossed in front of him, his face is turned down. The legs are bent at the knees at a right angle, the knees are closed, the legs and feet are close to each other. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans forward slightly on the patient and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient leaves his gaze directed downward on the table, makes a smooth exhalation (respiratory synergy), relaxes the muscles, the forehead rests on the crossed hands in front of him. At the same time, the doctor moves his lower legs in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans forward slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the piriform, external obturator muscles and musculo-ligamentous apparatus of the gluteal regions (abducting and rotating the hip outwards), hip and knee joints with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. It is necessary to strive to bring the feet closer to the table. Then the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of motion of both legs in abduction-adduction is approximately 15-50 °. The number of repeated cycles is 3-5 in one session. The impact is performed simultaneously on both legs.

X. The pressure of myofascial trigger points in the neutral position of the spine and lower extremities lying on the back in the neutral position of the spine and lower extremities.

Starting position: the patient lies on his back. Under the knees are three ergonomic cushions folded in a pyramid. The patient's legs are bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral (half-bent and divorced) position of the legs and a neutral (not bending, not bending) POP position are created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

The doctor rises from the side of his sore leg and palpation determines myofascial trigger points (MPTP). Most often they are located on the front-side surface of the thigh. There may be other localizations of MPTP, in particular, on the inner surface of the thigh. The bent finger in the first interphalangeal joint III finger slowly begin to exert pressure on the trigger zone. The pressure intensity within 1 minute should increase to 10-15 kg. It is necessary to choose the direction of pressure in the direction of solid tissue (bone, ligament, fascia), avoiding direction in the direction of large vessels and nerves. The duration of the procedure is 3-5 minutes.

Xi. Post-activation stretching of the anterolateral group of the musculo-ligamentous apparatus of the lower leg (extensors of the foot and I finger) and ankle joint in flexion in the neutral position of the spine and lower extremities.

Starting position: the patient lies on his back. Under the knees are three ergonomic cushions folded in a pyramid. The patient's legs are bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral (half-bent and divorced) position of the legs and a neutral (not bending, not bending) POP position are created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s sore foot. Three ergonomic cushions folded by a pyramid move under a healthy leg. One leg of the doctor, bent at the knee and hip joints, lies on the table with his lower leg. The patient’s straight, stretched leg rests on the thigh of the doctor’s leg with the Achilles tendon. The doctor holds the patient’s knee with one hand, the other fixes his foot. The patient’s face and gaze are directed upward towards the ceiling, he exhales (breathing synergy) and relaxes the muscles. The doctor performs a smooth preliminary passive stretching of the anterolateral group of the musculo-ligamentous apparatus of the lower leg and ankle joint, producing plantar flexion of the patient's foot until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient leaves his gaze directed upward at the ceiling, takes a smooth breath (breathing synergy), while his head remains in place. Simultaneously with the force of 50% of the maximum possible, the foot begins to put pressure on the doctor’s hand, producing back extension of the foot and I finger. In this case, the patient’s straight leg also presses down on the doctor’s thigh. The amplitude of the foot movement depends on the border of the passive movement achieved during the preliminary passive stretching or repeated passive stretching. At the same time, the doctor performs inferior work, resisting the hand and slightly shifting the weight of his body in the same direction. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed upward at the ceiling, his head remains in place. The final phase of the back extension of the foot, I finger and muscle and ligament tension is maintained in isometric mode with a force of 50% of the maximum possible. The doctor fixes this position, resisting the hand and slightly shifting the weight of his body in the same direction. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient leaves his gaze directed upward at the ceiling, performs a smooth exhalation (breathing synergy) and relaxes the muscles, while his head remains in place. At the same time, the doctor performs plantar flexion of the foot. Upon reaching the initial border of passive movement, the doctor deviates slightly towards the foot and, using the weight of his body, conducts a smooth repeated passive stretching of the anterior-lateral group of the musculo-ligamentous apparatus of the lower leg and ankle joint. The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. At the end of this stage, the doctor performs 5-10 swaying movements in the same direction, enhancing the effect of stretching. The duration of the stage is 8-10 seconds.

To further raise the leg up, the position of the doctor in relation to the patient changes: his thigh moves under the middle of the patient's calf muscle. The subsequent steps of the PAR are performed as described above.

The following position: the patient lies the same way, and the doctor puts his foot in the foot on the table. The patient’s leg lies on the doctor’s thigh with an Achilles tendon. Subsequent stages of PAR are described above.

The following position: the patient lies the same way, the doctor puts his foot on the table with his foot and moves his hip under the middle of the patient's calf muscle. Subsequent stages of PAR are described above.

The amplitude of the foot in extensional flexion is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Another embodiment of stretching the anterolateral group of the musculo-ligamentous apparatus of the lower leg and ankle joint can be carried out. For this, the forearm is first used as a support for the patient’s leg, and then, with further stretching of the musculo-ligamentous apparatus, the physician’s shoulder girdle. The stages of preliminary passive stretching, isotonic and isometric activations, repeated passive stretching are performed similarly to the option described above.

XII. Post-activation stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg (flexor of the foot) and ankle joint in extension in the neutral position of the spine and lower extremities.

Starting position: the patient lies on his back. Under the knees are three ergonomic cushions folded in a pyramid. The patient's legs are bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral (half-bent and divorced) position of the legs and a neutral (not bending, not bending) POP position are created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s sore foot. Three ergonomic cushions folded by a pyramid move under a healthy leg. One leg of the doctor, bent at the knee and hip joints, lies on the table with his lower leg. The patient’s straight, stretched leg rests on the thigh of the doctor’s leg with the Achilles tendon. The doctor holds the patient’s hip or pelvis with one hand, and fixes his foot with the other. The patient’s face and gaze are directed upward towards the ceiling, he exhales (breathing synergy) and relaxes the muscles. The doctor performs a smooth preliminary passive stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg and ankle joint, performing back extension of the patient’s foot to the border of passive movement with moderate pain in the patient. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient leaves his gaze directed upward at the ceiling, takes a smooth breath (breathing synergy), while his head remains in place. At the same time as a force of 50% of the maximum possible, he begins to put a foot on the doctor’s hand, producing plantar flexion. In this case, the patient’s straight leg also presses down on the doctor’s thigh. The amplitude of the foot movement depends on the border of the passive movement achieved during the preliminary passive stretching or repeated passive stretching. At the same time, the doctor performs inferior work, resisting the hand and slightly shifting the weight of his body in the opposite direction. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed upward at the ceiling, his head remains in place. The final phase of plantar flexion of the foot and tension of muscles and ligaments is maintained in isometric mode with a force of 50% of the maximum possible. The doctor fixes this position, resisting the hand and slightly shifting the weight of his body in the opposite direction. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient leaves his gaze directed upward at the ceiling, performs a smooth exhalation (breathing synergy) and relaxes the muscles, while his head remains in place. At the same time, the doctor performs back extension of the foot. Upon reaching the initial border of passive movement, the doctor slightly deviates to the side and, using the weight of his body, conducts a smooth repeated passive stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg and ankle joint. The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. At the end of this stage, the doctor performs 5-10 swaying movements in the same direction, enhancing the effect of stretching. The duration of the stage is 8-10 seconds.

To further raise the leg up, the position of the doctor in relation to the patient changes: his thigh moves under the middle of the patient's calf muscle. The subsequent steps of the PAR are performed as described above.

The following position: the patient lies the same way, and the doctor puts his foot in the foot on the table. The patient’s leg lies on the doctor’s thigh with an Achilles tendon. With one hand, the doctor rests on the table, transferring body weight to it, with the other hand fixes the patient’s foot. Subsequent stages of PAR are described above.

The following position: the patient lies the same way, the doctor puts his foot on the table with his foot and moves his hip under the middle of the patient's calf muscle. Subsequent stages of PAR are described above.

The amplitude of the foot in extensional flexion is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Another embodiment of stretching the posterior group of the musculo-ligamentous apparatus of the lower leg and ankle joint can be carried out. For this, the forearm is first used as a support for the patient’s leg, and then, with further stretching of the musculo-ligamentous apparatus, the physician’s shoulder girdle. The stages of preliminary passive stretching, isotonic and isometric activations, repeated passive stretching are performed similarly to the variant described above.

Xiii. Post-activation stretching of the sacro-tuberous ligament, the musculo-ligamentous apparatus of the gluteal region (hip extensors) and the hip joint in flexion in the neutral position of the spine and lower extremities.

Starting position: the patient lies on his back. Under the knees are three ergonomic cushions folded in a pyramid. The patient's legs are bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral (half-bent and divorced) position of the legs and a neutral (not bending, not bending) POP position are created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s sore foot. Three ergonomic cushions folded by a pyramid move under a healthy leg. The patient’s stretched leg is bent at the knee and hip joints, his hands are locked together and fix the hip under the knee joint. The face and gaze are directed upward to the ceiling, the patient exhales (breathing synergy) and relaxes the muscles. The doctor stands with his back to the stretched leg and fixes her knee and foot under the armpits. The doctor presses on the patient's knee, bringing him closer to the chest in the direction of the shoulder of the same name. In this case, a smooth preliminary passive stretching of the sacro-tubercular ligament, the musculo-ligamentous apparatus of the gluteal region (hip extensors) and the hip joint occurs until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient leaves his gaze directed upward at the ceiling, takes a smooth breath (breathing synergy), while his head remains in place. At the same time, he performs a knee movement in the direction from the shoulder of the same name, unbending the leg in the hip joint with a force of 50% of the maximum possible. The amplitude of the leg movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. At the same time, the doctor leans slightly on his leg and, resisting his weight, performs inferior work. The final phase of the leg movement is limited by the length of the patient's bent arms that fix his thigh. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed upward at the ceiling, his head remains in place. The angle between the patient’s thigh and the horizontal plane of the torso is 75-80 °. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans slightly on the leg and, using the weight of his body, fixes this position. The patient holds his thigh with his hands, which reduces the physical effort of the doctor. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient leaves his gaze directed upward at the ceiling, performs a smooth exhalation (breathing synergy) and relaxes the muscles, while his head remains in place. At the same time, the doctor moves the patient's knee in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans slightly on the leg and, using the weight of his body, conducts a smooth repeated passive stretching of the sacro-tuberous ligament, the musculo-ligamentous apparatus of the gluteal region (hip extensors) and the hip joint. The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain for the patient. It is necessary to strive to put the patient's hip on the costal arch from the same side. The relaxed coupled hands of the patient retain their position under the knee joint. The doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of the hip movement in flexion-extension is 15-45 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Xiv. Post-activation stretching of the posterior group of the musculo-ligamentous apparatus of the thigh, gluteal region (hip extensors), knee and hip joints in flexion, lower leg (flexor of the foot) and ankle joint in extension in the neutral position of the spine and lower extremities.

Starting position: the patient lies on his back. Under the knees are three ergonomic cushions folded in a pyramid. The patient's legs are bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral (half-bent and divorced) position of the legs and a neutral (not bending, not bending) POP position are created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s sore foot. Three ergonomic cushions folded by a pyramid move under a healthy leg. The patient’s stretched leg is bent at the hip and knee joints, the foot is in a state of back extension in the ankle joint and the Achilles tendon lies on the physician’s shoulder. The patient’s same hand holds on to the back of the thigh, the other lies on the table. The patient’s face and gaze are directed upward towards the ceiling, he exhales (breathing synergy) and relaxes the muscles. The doctor fixes the patient’s foot with his hand and leans forward, bringing the patient’s hip and knee closer to his costal arch. At the same time, it enhances the flexion of the leg in the knee and hip joints and the extension of the foot in the ankle joint. There is a smooth preliminary passive stretching of the posterior group of the musculo-ligamentous apparatus of the thigh and lower leg, hip, knee and ankle joints (extensor femur and flexor of the foot) until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient leaves his gaze directed upward at the ceiling, takes a smooth breath (breathing synergy), while his head remains in place. At the same time, he begins to press his foot on the doctor with a force of 50% of the maximum possible, unbending it in the hip, knee joints and performing plantar flexion of the foot in the ankle joint. It is necessary to strive for full straightening of the leg in the knee and ankle joints, while the final angle between the straight leg and the plane of the table depends on the severity of muscle tone and ligaments. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. One doctor’s hand lies on the sole of the patient’s foot, resisting it, the other presses on the knee joint, helping the patient’s leg straighten. Tension of the ischiocrural muscle group and ligaments occurs. In this case, the doctor leans forward slightly and, using the weight of his body, counteracts. The final phase of the leg movement is limited by the length of the patient’s bent arm of the same name, which fixes his hip. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed upward at the ceiling, his head remains in place. The final phase of leg straightening and plantar flexion of the foot is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans forward slightly and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient leaves his gaze directed upward at the ceiling, performs a smooth exhalation (breathing synergy) and relaxes the muscles, while his head remains in place. At the same time, the doctor moves the patient’s hip and knee in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans slightly forward and, using the weight of his body, conducts a smooth repeated passive stretching of the posterior group of the musculo-ligamentous apparatus of the thigh and lower leg, hip, knee and ankle joints (flexors of the foot and extensors of the thigh). The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. In this case, the patient’s leg extends in the ankle and bends in the knee and hip joints. It is necessary to strive to ultimately put the front surface of his thigh on the stomach and costal arch on the same side. The duration of the stage is 8-10 seconds. To enhance the stretching of the muscles and ligaments of the posterior thigh, the doctor, using the weight of his body, presses the patient's leg bent in the hip and knee joint to his stomach and costal arch. To enhance the stretching of the muscles and ligaments of the lower leg, the doctor leans back and straightens the patient's relaxed leg to a vertical position due to pressure on the knee joint. In patients with well-stretched muscles and ligaments, the doctor fixes the straightened knee joint with one hand, and the heel and sole of the foot with the other hand. After that, he makes 5-10 additional tensile movements on the musculo-ligamentous apparatus of the lower leg due to the strengthening of the back extension of the foot. The number of repetitions is 2-3.

The joint amplitude of the movement of the leg in flexion-extension is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Xv. Post-activation stretching of the sacrospinous, sacroiliac ligaments, the musculo-ligamentous apparatus of the gluteal region (diverting and rotating the hip outward) and the hip joint in adduction in the neutral position of the spine and lower extremities.

Starting position: the patient lies on his back. Under the knees are three ergonomic cushions folded in a pyramid. The patient's legs are bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral (half-bent and divorced) position of the legs and a neutral (not bending, not bending) POP position are created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The doctor rises from the patient’s sore foot. Three ergonomic cushions folded by a pyramid move under a healthy leg. The stretched leg is bent at the knee and hip joints, its brush of the same name is located in the popliteal bend, and the opposite one on the foot of the sore foot. The patient’s face and gaze are directed upward towards the ceiling, he exhales (breathing synergy) and relaxes the muscles. The doctor conducts a smooth preliminary passive stretching of the sacrospinous, sacroiliac ligaments, the musculo-ligamentous apparatus of the gluteal region and the hip joint (leading and rotating the hips outwards) until the border of passive movement with moderate pain for the patient is reached. At the same time, he brings the patient's knee to the opposite shoulder and fixes it with his forearm. The doctor fixes the foot of this leg with the brush of the other hand. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient leaves his gaze directed upward at the ceiling, takes a smooth breath (breathing synergy), while his head remains in place. At the same time, the patient performs a knee movement in the direction from the opposite shoulder, deflecting the leg in the hip joint with a force of 50% of the maximum possible. The amplitude of the leg movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. The final phase of the leg movement is limited by the length of the patient's extended arms, which fixes his knee joint and foot. In this case, the doctor leans slightly forward and, using the weight of his body, exerts resistance, and also helps to correctly implement the trajectory of movement by fixing the foot. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed upward at the ceiling, his head remains in place. The final phase of the movement is maintained in isometric mode with a force of 50% of the maximum possible. The angle between the patient’s hip and the horizontal plane is 75-80 °, and the lower leg and foot are rotated inward. The patient holds his knee joint and foot with his hands, which reduces the physical effort of the doctor. In this case, the doctor leans forward slightly and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient leaves his gaze directed upward at the ceiling, performs a smooth exhalation (breathing synergy) and relaxes the muscles, while his head remains in place. At the same time, the doctor moves the patient's knee in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans slightly forward and, using the weight of his body, conducts a smooth repeated passive stretching of the sacrospinous, sacroiliac ligaments, musculo-ligamentous apparatus of the gluteal region and the hip joint (leading and rotating the hip outwards). The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. The doctor tries to bring the knee of the stretched leg closer to the opposite half of the chest. Relaxed hands of the patient retain their position on the knee joint and foot. Then the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The amplitude of the hip movement in adduction-abduction is 15-45 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Xvi. Post-activation stretching of the lateral and posterior groups of the musculo-ligamentous apparatus of the thigh, gluteal region (abduction and extension of the thigh) and hip joints in adduction in the neutral position of the spine and lower extremities.

Starting position: the patient lies on his side. The lower half-bent in the hip, in the knee joints leg and body of the patient is given a position at an obtuse angle open anteriorly. Due to this, a neutral (half-bent) position of the leg and a neutral (not bending, not bending) POP position are created. The patient's overlying leg is bent at the hip and knee joints, her foot lies in the popliteal fossa. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, the neutral (not bending, not bending) position of the SHOP and GOP is formed. The neutral position of the underlying lower limb, the neutral position of POP, GOP and SHOP form a neutral position of the spine and lower limbs.

1. Preliminary passive stretching.

The patient’s stretched (overlying) leg, bent at the hip and knee joints, lowers and is located outside the table, while the foot rests on the doctor’s thigh with the Achilles tendon. The far arm of the patient is held by the edge of the table, and the near arm rests on top of the thigh of the stretched leg. The patient’s face and gaze are directed upward towards the ceiling, he exhales (breathing synergy) and relaxes the muscles. The doctor fixes the patient’s knee with one hand and fixes the patient’s thigh with the other hand to the table. This is necessary to prevent it from bending when stretching the stretched leg. The doctor moves sideways and brings the inner surface of the patient's thigh and knee closer to the edge of the table. At the same time, it enhances the flexion of the leg in the knee and hip joints. There is a smooth preliminary passive stretching of the lateral and posterior groups of the musculo-ligamentous apparatus of the thigh (abduction and extension of the thigh) and the hip joints until the border of passive movement with moderate pain in the patient is reached. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient leaves his gaze directed upward at the ceiling, takes a smooth breath (breathing synergy), while his head remains in place. At the same time, he begins to press with his foot on the doctor with a force of 50% of the maximum possible, unbending it in the hip and knee joints. It is necessary to strive for full straightening of the leg in the knee joint, while the final angle between the stretched and healthy leg depends on the severity of muscle tone and ligaments. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. One doctor’s hand lies on the thigh of the patient’s healthy leg, the other presses on the knee joint of the sore leg, helping her straighten. There is tension of the abducent and ischiocrural muscle groups and ligaments. In this case, the doctor leans slightly on the stretched leg and, using the weight of his body, provides resistance. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed upward at the ceiling, his head remains in place. The final phase of leg straightening is maintained in isometric mode with a force of 50% of the maximum possible. In this case, the doctor leans slightly on the stretched leg and, using the weight of his body, fixes this position. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient leaves his gaze directed upward at the ceiling, performs a smooth exhalation (breathing synergy) and relaxes the muscles, while his head remains in place. At the same time, the doctor moves the patient’s hips and knees in the opposite direction, during which the patient’s sore leg bends at the knee and hip joints. Upon reaching the initial border of passive movement, the doctor leans slightly on the stretched leg and, using the weight of his body, conducts a smooth repeated passive stretching of the lateral and posterior groups of the musculo-ligamentous apparatus of the thigh and hip joints (abduction and extension of the thigh). The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. It is necessary to strive in the end, to bring the inner surface of the patient's hip and knee closer to the edge of the table. Then the doctor performs 5-10 swaying movements in the direction of the performed stretching. The duration of the stage is 8-10 seconds.

The joint amplitude of leg movement in adduction-abduction and flexion-extension is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Xvii. Post-activation stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg (flexor of the foot) and ankle joint in extensia while lying on the stomach in the neutral position of the spine and lower extremities.

Starting position: the patient lies on his stomach, his legs lie on the table. The forehead is on the hands crossed in front of it, the chin is in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. An ergonomic pillow lies under the patient’s stomach and pelvis. Due to this, the lowering of the lower back is eliminated and a neutral (not bending, not bending) position of the POP is created. Under the ankle joints lies an ergonomic roller, the legs are slightly bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral position of the legs is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

1. Preliminary passive stretching.

The patient’s stretched leg bends at the knee joint, and the hip lies on the table. The doctor holds the patient’s hip or pelvis with one hand, and fixes his foot with the other. The patient's face and gaze are directed downward, he makes a smooth exhalation (respiratory synergy) and relaxes the muscles. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The doctor performs a smooth preliminary passive stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg and ankle joint, performing back extension of the patient’s foot to the border of passive movement with moderate pain in the patient. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient leaves his gaze directed down at the table, takes a smooth breath (respiratory synergy), while his head remains in place. At the same time, the patient with a force of 50% of the maximum possible begins to smoothly press his foot on the doctor’s hand, producing plantar flexion. The amplitude of the foot movement depends on the border of the passive movement achieved during the preliminary passive stretching or repeated passive stretching. At the same time, the doctor performs inferior work, resisting the hand and slightly shifting the weight of his body in the opposite direction. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed down to the table, his head is lowered forehead to the hands crossed in front of him, his face is turned down. The final phase of plantar flexion of the foot and tension of muscles and ligaments is maintained in isometric mode with a force of 50% of the maximum possible. The doctor fixes this position, resisting the hand and slightly shifting the weight of his body in this direction. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient leaves his gaze directed downward on the table, makes a smooth exhalation (respiratory synergy), relaxes the muscles, the forehead rests on the crossed hands in front of him. At the same time, the doctor performs a smooth back extension of the foot. Upon reaching the initial border of passive movement, the doctor leans slightly and, using the weight of his body, conducts a smooth repeated passive stretching of the posterior group of the musculo-ligamentous apparatus of the lower leg and ankle joint. The impact is carried out with a force of 50% from the maximum possible to a new border of passive movement with moderate pain in the patient. At the end of this stage, the doctor performs 5-10 swaying movements in the same direction, enhancing the effect of stretching. The duration of the stage is 8-10 seconds.

The amplitude of the foot in flexion-extension is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed on a sore foot.

Xviii. Pressurization of myofascial trigger points in the neutral position of the spine and lower extremities lying on the stomach.

At the stage of regression of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can lie on their stomachs, one styling option with a neutral position of the spine and lower extremities is used.

Starting position No. 1: the patient lies on his stomach, his legs lie on the table. The forehead is on the hands crossed in front of it, the chin is in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. An ergonomic pillow lies under the patient’s stomach and pelvis. Due to this, the lowering of the lower back is eliminated and a neutral (not bending, not bending) position of the POP is created. Under the ankle joints lies an ergonomic roller, the legs are slightly bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral position of the legs is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

In the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when due to the flexion component in the neutral myofixation of the lower limb and spine, patients cannot lie on their stomachs, another option of laying in the neutral position of the spine and lower extremities is used.

Starting position No. 2: the patient lies chest, stomach and pelvis on the table. The forehead is on the hands crossed in front of it, the chin is in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. An ergonomic pillow lies under the patient’s stomach and pelvis. Due to this, the lowering of the lower back is eliminated and a neutral (not bending, not bending) position of the POP is created. A chair is set to the table, with its back turned to its edge. The bent legs of the patient rest with their legs on the seat of the attached chair, the knees are slightly divorced, and the hips rest against the back of the chair. Due to this, a neutral (half-bent and divorced) position of the legs is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

The doctor rises from the side of his sore leg and palpation determines myofascial trigger points (MPTP). Most often they are located on the back surface of the lower leg, in the gluteal region and paravertebral muscles near the affected PDS. There may be other localizations of MPTP, in particular on the posterior surface of the thigh. The bent finger in the first interphalangeal joint III finger slowly begin to exert pressure on the trigger zone. The pressure intensity within 1 minute should increase to 10-15 kg. It is necessary to choose the direction of pressure in the direction of solid tissue (bone, ligament, fascia), avoiding direction in the direction of large vessels and nerves. The duration of the procedure is 3-5 minutes. The pressure of the revealed gluteal MPTP is carried out by the elbow.

XIX. Post-activation stretching of the musculo-ligamentous apparatus of the thoracic, lumbar spine, pelvis, ileo-lumbar ligament with tension and vibrational displacement of the dural sac in rotation in the neutral position of the spine and lower extremities.

Starting position: the patient lies on a sick (let's say left) side. The lower half-bent in the hip, in the knee joints leg and body of the patient is given a position at an obtuse angle, open anteriorly. Due to this, a neutral (half-bent) position of the leg and a neutral (not bending, not bending) POP position are created. The patient's overlying leg is bent at the hip and knee joints, her foot lies in the popliteal fossa. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, the neutral (not bending, not bending) position of the SHOP and GOP is formed. The neutral position of the underlying lower limb, the neutral position of POP, GOP and SHOP form a neutral position of the spine and lower limbs.

1. Preliminary passive stretching.

The doctor rises from the back of the patient. The patient's body is deployed towards the doctor, while the face and chest are directed to the ceiling. The hand nearest to the doctor is bent at the elbow and set aside, and the far hand rests with the palm on the stomach. The doctor fixes the elbow of the near hand with his hand, bringing it closer to the table. A wrist or fist of the doctor’s other hand fixes the patient’s knee joint from above and also brings it closer to the table. The patient looks to the right (oculomotor synergy), makes a smooth exhalation (respiratory synergy) and smoothly relaxes the muscles. The doctor conducts a smooth preliminary passive stretching of the right half of the musculo-ligamentous apparatus of the thoracic, lumbar spine, pelvis and ileo-lumbar ligament in rotation with a neutral POP position until the patient reaches the border of passive movement with moderate pain. In this case, the doctor enhances the turn of the patient's body, bringing his near elbow and knee of the overlying leg to the table. The spine takes the form of the letter S with the left concave side of the deformity in the lumbar and thoracic spine. In this case, the dural sac is stretched and displaced in the epidural space to the left side wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

2. Isotonic activation.

The patient looks away from the doctor - to the left (oculomotor synergy), takes a smooth breath (respiratory synergy) and at the same time carries out a smooth rotational movement with the body and leg with a force of 50% of the maximum possible. The amplitude of the movement depends on the border of the passive movement achieved during the preliminary passive extension or repeated passive extension. The chest and head rotate from the doctor; overlying leg and pelvis - to the doctor, resting on the foot. In the final phase of the movement, the patient’s face and chest are deployed from the doctor, and the pelvis and knee to the doctor, with the knee pointing to the ceiling. POP is in the neutral position. The patient’s near arm is wrapped behind the back, and her elbow is fixed with the doctor’s brush. The knee rests on the doctor’s straightened hand, the foot rests on the table and the doctor’s fist standing on the table. In this case, the tension of the dural sac weakens, and it shifts to the center of the spinal canal, which weakens the compression of venous and lymphatic vessels in the epidural space, weakens the stretching of scars and adhesions in the epidural space. At the same time, the doctor leans forward slightly and, using the weight of his body, performs inferior work. The duration of the stage is 4-5 seconds.

3. Isometric activation.

The patient holds his breath (respiratory synergy), his gaze is directed away from the doctor - to the left (oculomotor synergy). The doctor leans forward slightly and, using his weight, fixes the final phase of the patient's rotational movement in isometric mode with a force of 50% of the maximum possible. In this case, there is no tension in the dural sac, and it is located in the center of the spinal canal, there is no compression of the venous and lymphatic vessels, and there is no stretching of scars and adhesions in the epidural space. The duration of the stage is 4-5 seconds.

4. Repeated passive stretching.

The patient looks to the right (oculomotor synergy), performs a smooth exhalation (respiratory synergy) and relaxes the muscles, while the doctor rotates the patient's body in the opposite direction. Upon reaching the initial border of passive movement, the doctor leans slightly forward and, using the weight of his body, performs a smooth repeated passive stretching of the musculo-ligamentous apparatus of the thoracic, lumbar spine (spinal rotators), pelvis and ileo-lumbar ligament in rotation in the neutral POP position. The impact is carried out with a force of 50% of the maximum possible, achieving a new border for passive movement with moderate pain in the patient. Fixation of the patient’s near arm behind the back stops, and the elbow is moved to the side, fixation of the arm farthest to the doctor on the stomach remains. In this case, it is necessary to strive so that the knee of the overlying leg and the elbow of the hands closest to the doctor are pressed against the table. The spine takes the form of the letter S with the left concave side of the deformity in the lumbar and thoracic spine. In this case, the dural sac is stretched and displaced in the epidural space to the left side wall of the spinal canal with compression of venous and lymphatic vessels in the epidural space, with stretching of scars and adhesions in the epidural space.

At the end of this stage, the doctor performs 5-10 swaying movements in the same direction, enhancing the effect of stretching. The duration of the stage is 8-10 seconds.

The joint amplitude of movement of the thoracic, lumbar spine and pelvis of the patient in rotation in the neutral position of POP is 15-90 °. The number of repeated cycles is 3-5 in one session. The impact is performed first on the healthy, and then on the diseased half of the EPP with stronger stretching on the sick side. In the presence of antalgic scoliosis, the effect is performed on only one side - on the side of antalgic scoliosis. At the end of the procedure, the patient is put on a rubber retainer on the shin of the overlying leg, and a sports weighting agent weighing 3-5 kg is placed on top of her thigh. The patient is given the overlying arm to the side and upward at an angle of 45 °, he relaxes and breathes calmly for 3-5 minutes. This exposure element greatly enhances the tensile effect.

XX. Mobilization of the sacroiliac joints of the pelvis in the neutral position of the spine and lower extremities.

At the stage of regression of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can lie on their stomachs, one laying option with a neutral position of the spine and lower extremities can be applied.

A) Mobilization of the blocked CPS in the patient’s supine position.

Starting position No. 1: the patient lies on his stomach, his legs lie on the table. The forehead is on the hands crossed in front of it, the chin is in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. An ergonomic pillow lies under the patient’s stomach and pelvis. Due to this, the lowering of the lower back is eliminated and a neutral (not bending, not bending) position of the POP is created. Under the ankle joints lies an ergonomic roller, the legs are slightly bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral position of the legs is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

The doctor mobilizes the blocked KPS according to V. Schneider and (or) according to A. Stoddart.

At the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of MPD POP, when due to the flexion component in the neutral myofixation of the lower limb and spine, patients cannot lie on their stomachs, two variants of laying in the neutral position of the spine and lower extremities are used.

B) Mobilization of blocked KPS in the patient's supine position.

Starting position No. 2: the patient lies on his back. Under the knees are three ergonomic cushions folded in a pyramid. The patient's legs are bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral (half-bent and divorced) position of the legs and a neutral (not bending, not bending) POP position are created. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP is created. The neutral position of the lower extremities, the neutral position of POP and SHOP form the neutral position of the spine and lower extremities.

Three ergonomic cushions folded by a pyramid move under a healthy leg. The doctor mobilizes the blocked CPS using the patient’s bent, injured leg as a lever.

C) It is also possible to carry out the mobilization of the blocked CPS in the position of the patient lying on his side.

Starting position No. 3: the patient lies on his side. The lower half-bent in the hip, in the knee joints leg and body of the patient is given a position at an obtuse angle, open anteriorly. Due to this, a neutral (half-bent) position of the leg and a neutral (not bending, not bending) POP position are created. The patient's overlying leg is bent at the hip and knee joints, her foot lies in the popliteal fossa. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, the neutral (not bending, not bending) position of the SHOP and GOP is formed. The neutral position of the underlying lower limb, the neutral position of POP, GOP and SHOP form a neutral position of the spine and lower limbs.

The doctor mobilizes the blocked CPS using the patient’s superior iliac wing as a lever.

Sometimes mobilization ends with manipulation. Receptions are repeated 10-30 times.

XXI. Manipulation treatment of the thoracic spine in the neutral position of the spine and lower extremities.

Reception XIX helps to improve blood supply (an equilibrium is achieved between arterial inflow and venous, lymphatic outflow), stretching the muscular-ligamentous apparatus of the GOP and serves as a preparation for subsequent safe manipulations.

At the stage of regression of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can lie on their stomachs, one styling option with a neutral position of the spine and lower extremities is used.

Starting position No. 1: the patient lies on his stomach, his legs lie on the table. The forehead is on the hands crossed in front of it, the chin is in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. An ergonomic pillow lies under the patient’s stomach and pelvis. Due to this, the lowering of the lower back is eliminated and a neutral (not bending, not bending) position of the POP is created. Under the ankle joints lies an ergonomic roller, the legs are slightly bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral position of the legs is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

In the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when due to the flexion component in the neutral myofixation of the lower limb and spine, patients cannot lie on their stomachs, another option of laying in the neutral position of the spine and lower extremities is used.

Starting position No. 2: the patient lies chest, stomach and pelvis on the table. The forehead is on the hands crossed in front of it, the chin is in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. An ergonomic pillow lies under the patient’s stomach and pelvis. Due to this, the lowering of the lower back is eliminated and a neutral (not bending, not bending) position of the POP is created. A chair is set to the table, with its back turned to its edge. The bent legs of the patient rest with their legs on the seat of the attached chair, the knees are slightly divorced, and the hips rest against the back of the chair. Due to this, a neutral (half-bent and divorced) position of the legs is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

The patient turns his head on his side, stretches his arms along the body, puts his hands under the anterior inner thighs. The patient undergoes targeted manipulations on the GOP using rotation and short levers. The number of PDS on which manipulations can be performed depends on the stage of myofixation in which the patient is located.

XXII. Mobilization of the skin of the lumbar spine in the neutral position of the spine and lower extremities.

At the stage of regression of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when patients can lie on their stomachs, one styling option with a neutral position of the spine and lower extremities is used.

Starting position No. 1: the patient lies on his stomach, his legs lie on the table. The forehead is on the hands crossed in front of it, the chin is in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. An ergonomic pillow lies under the patient’s stomach and pelvis. Due to this, the lowering of the lower back is eliminated and a neutral (not bending, not bending) position of the POP is created. Under the ankle joints lies an ergonomic roller, the legs are slightly bent at the knee and hip joints, knees and feet are slightly apart. Due to this, a neutral position of the legs is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

In the stage of exacerbation of the neurological manifestations of hernias and protrusions (prolapses) of the MPD POP, when due to the flexion component in the neutral myofixation of the lower limb and spine, patients cannot lie on their stomachs, another option of laying in the neutral position of the spine and lower extremities is used.

Starting position No. 2: the patient lies chest, stomach and pelvis on the table. The forehead is on the hands crossed in front of it, the chin is in the neutral position (not lowered, not raised). Due to this, a neutral (not bending, not bending) position of the SHOP, as well as the GOP, is created. An ergonomic pillow lies under the patient’s stomach and pelvis. Due to this, the lowering of the lower back is eliminated and a neutral (not bending, not bending) position of the POP is created. A chair is set to the table, with its back turned to its edge. The bent legs of the patient rest with their legs on the seat of the attached chair, the knees are slightly divorced, and the hips rest against the back of the chair. Due to this, a neutral (half-bent and divorced) position of the legs is created. The neutral position of the lower extremities, the neutral position of POP, GOP and SHOP form the neutral position of the spine and lower extremities.

The doctor palpation forms a fold of the skin and performs its displacement above the spinous processes of the upper sacral, lumbar and lower thoracic vertebrae. In this case, the skin stretches with a characteristic sound phenomenon in the form of a click. Reception is repeated 3 times.

Xxiii. Manipulation treatment of the lumbar spine in the neutral position of the spine and lower extremities.

By the end of the course of treatment, POP contracture is eliminated, and it becomes possible to use POP manipulations. Reception XIX and XXII helps to improve blood supply (a balance is achieved between arterial inflow and venous, lymphatic outflow), stretching of the musculo-ligamentous apparatus, skin POP and serve as a preparation for subsequent safe manipulations.

Starting position: the patient lies on a sick (let's say left) side. The lower half-bent in the hip, in the knee joints leg and body of the patient is given a position at an obtuse angle, open anteriorly. Due to this, a neutral (half-bent) position of the leg and a neutral (not bending, not bending) POP position are created. The patient's overlying leg is bent at the hip and knee joints, her foot lies in the popliteal fossa. Under the head and neck lies an ergonomic pillow, the chin in the neutral position (not lowered, not raised). Due to this, the neutral (not bending, not bending) position of the SHOP and GOP is formed. The neutral position of the underlying lower limb, the neutral position of POP, GOP and SHOP form a neutral position of the spine and lower limbs.

The patient is manipulated on healthy lumbar PDS on both sides using rotation and counter-retention in the neutral position of the spine. Manipulations on POP are performed provided that the hernias of the MPD POP are without sequestration, and their size is not more than 1 cm in depth.

Examples of specific performance are given in the form of extracts from medical records. Patients with large hernias and sequestered hernias who had extravertebral syndromes were demonstrated. Known methods were used for their treatment (Manual exposure method according to V. K. Kalabanov. Patent for invention No. 2237459 dated 10.10.04; Method for the complex treatment of neurological manifestations of hernias and protrusions of the lumbar intervertebral discs according to V. K. Kalabanov. Patent for the invention No. 2287317 dated 11/20/06). To select the tactics of using MT techniques, the claimed method was used.

Example No. 1.

Patient K., 57 years old, engineer. Received treatment with a diagnosis of Discogenic radiculopathy L3, L4 roots on the left, the stage of exacerbation, severe pain, stationary course.

Complaints upon admission: pain in the lower back, left buttock with radiation to the left inguinal region, the front and side surfaces of the left thigh, aggravated by movements, at night, weakness in the muscles of the left thigh, burning sensation in the front and side surfaces of the left thigh.

Medical history: for the first time, back pain appeared ~ 6 years ago after exercise. During this period there were 2 exacerbations. In the last 3rd exacerbation of pain in the lower back joined pain in the left lower limb. The exacerbation of the disease occurred after exercise, lasted 1.5 months, the patient underwent outpatient medication and physiotherapy.

Received treatment by the claimed method in connection with the lack of effectiveness of conservative therapy.

Neurological status: positive symptoms of muscle tension, flexion (Wasserman and Matskevich) and leading the left thigh (Patrick); strength in muscles flexing and leading the left thigh is reduced to 3 points; hypotrophy of the muscles of the left thigh; reduced knee and Achilles reflexes on the left (D> S); hypesthesia and areas of anesthesia in the innervation zone of the left L3, L4 roots; foci of neurodystrophy in the quadriceps muscle of the left thigh - 3 points; pain on the VAS scale - 7 points.

According to a neurological study, the patient had extravertebral radicular syndromes (radiculopathy L3, L4 roots on the left) with the included muscular-tonic manifestations, anatomically associated with the lumbar plexus.

According to an MRI scan of the lumbosacral spine: dorsal left-sided paramedian-foraminal hernia of the LII-LIII disc, 0.8 cm in size, extending cranially by 0.8 cm; dorsal median disc herniation LIV-LV, 0.5 cm in size; Dorsal diffuse protrusions of the disks LIII-LIV and LV-SI, 0.3 and 0.4 cm in size, respectively (Fig. 9, Fig. 10).

The treatment was carried out according to the claimed method, which consisted of the actual manual exposure, medication (non-steroidal anti-inflammatory drugs, muscle relaxants, B vitamins, venotonics and angioprotectors, cholinesterase inhibitors) and wearing a lumbar corset in an upright body position. The neurological principle was the basis for choosing the tactics of manual therapy. The patient revealed extravertebral syndromes anatomically associated with the lumbar plexus, in which the flexor myofixation of the lower limb is formed (due to muscle tension of the flexors that drive and rotate the outside of the thigh) and, accordingly, the flexion sanogenizing myofixation of the PDS POP (due to muscle tension of the flexing POP), as well as flexion myofixation of GOP and SHOP. The applicant author applied treatment tactics in the flexion position of the spine and lower extremities. MT receptions were performed, starting from the peripheral parts of the body (SHOP and lower limb) and ending in EPP.

This made it possible to treat the neurological manifestations of hernias and protrusions of the lumbar intervertebral discs and to save the flexion sanogenizing myofixation of the damaged PPS POP, which limits their extension. In this case, there was no increase in pressure in the damaged disk during the execution of MT techniques, and therefore there was no danger of an increase in the size of the hernia or its sequestration. The patient received 2 procedures per week, only 10 procedures for 1.5 months. A good clinical result was achieved: negative symptoms of tension; increased muscle strength, flexing and adducing the left thigh, from 3 to 4 points; the left knee and Achilles reflexes recovered (D = S); Anesthesia passed, but small areas of hypesthesia remained in the innervation zone of the left L3 and L4 roots; burning sensation in left hip passed; neurodystrophic syndrome decreased from 3 to 1 point; pain on the scale of YOUR decreased from 7 to 0 points.

Control examination after 6 months: negative symptoms of tension; the strength of the muscles that bend and adduce the left thigh - 5 points; knee and Achilles reflexes (D = S); small areas of hypesthesia remain in the innervation zone of the left L3 and L4 roots; neurodystrophic syndrome in the quadriceps muscle of the left thigh - 0 points; pain on the YOUR scale - 0 points.

According to the control MRI study of the lumbosacral spine: dorsal left-sided paramedian-foraminal hernia of the LII-LIII disk, 0.6 cm in size; at other levels without significant dynamics (Fig. 11, Fig. 12).

Compared with the initial MRI scan, there is a positive trend in the form of regression of the hernia of the disc at the level of LII-LIII: the absence of a cranially directed part of the hernia of the disc and a decrease in its dorsal size from 0.8 cm to 0.6 mm.

Example No. 2.

Patient S. 32, seller. Received treatment with a diagnosis of Discogenic radiculopathy S1 root on the left, acute stage, severe pain, moderate paresis of the flexors of the left foot.

Complaints upon admission: burning pains in the left buttock with radiation to the left thigh and lower leg, aggravated by movement, weakness in the muscles of the left foot, as well as paresthesia in the left foot (outer edge of the foot and V, IV, III fingers).

Medical history: for the first time, back pain appeared ~ 10 years ago after exercise. Exacerbations occurred 2 times a year. Over the past year, I felt constant pain in the lower back. During the last exacerbation, severe pain developed in the left buttock, thigh, lower leg and paresis of the left foot developed, after which the pain in the lower back was significantly reduced. The exacerbation of the disease occurred after exercise, lasted 1.5 months, the patient underwent inpatient treatment, then was on an outpatient medical and physiotherapeutic treatment.

Received treatment by the claimed method in connection with the lack of effectiveness of conservative therapy.

Neurological status: positive symptoms of Neri tension, extensor muscles of the left lower limb (Lasega and Kernig from an angle of 50 °); the strength of the muscles of the flexors of the left foot is reduced to 3 points; knee reflexes (D = S), there is no left Achilles reflex (DnSabs); hypesthesia on the left lower leg and foot in the innervation zone S1 of the root; foci of neurodystrophy in the left gastrocnemius muscle - 2 points; pain on the VAS scale - 7 points.

According to a neurological study, the patient had an extravertebral radicular syndrome (radiculopathy of the S1 radicle on the left) with muscular-tonic manifestations included in it, anatomically associated with the sacral plexus.

According to an MRI scan of the lumbosacral spine: left-side sequestered hernia of the LV-SI disc, dorsal size 1.2 cm, base 2.9 cm, spread caudally along the vertebral body SI up to 3.1 cm; 0.4 cm dorsal protrusion of the LIII-LIV disk (Fig. 13, Fig. 14).

The treatment was carried out according to the claimed method, which consisted of the actual manual exposure, medication (steroidal and non-steroidal anti-inflammatory drugs, muscle relaxants, B vitamins, venotonics and angioprotectors, cholinesterase inhibitors) and wearing the lumbosacral corset in the vertical position of the body. The neurological principle was the basis for choosing the tactics of manual therapy. The patient revealed extravertebral syndrome, anatomically associated with the sacral plexus, in which extensor myofixation of the lower extremity is formed (due to muscle tension, extensor, abducting and rotating the hip outward) and, accordingly, extensor sanogenizing myofixation of the PPS POP (due to muscle tension, extensor POP ), as well as extensor myofixation of GOP and SHOP. The applicant author applied treatment tactics in the extensor position of the spine and lower extremities. MT receptions were performed, starting from the peripheral parts of the body (SHOP and lower limb) and ending in EPP.

This made it possible to treat the neurological manifestations of hernias and protrusions of the lumbar intervertebral discs and to preserve extensor sanogenizing myofixation of damaged POP PDS, which limits their flexion. In this case, there was no increase in pressure in the damaged disc during the execution of MT techniques, and therefore there was no danger of an increase in the size of the hernial sequestration. The patient received 2-3 procedures per week, only 10 procedures for 1 month. A good clinical result was achieved: negative symptoms of tension; the strength of the muscles flexing the left foot increased from 3 to 5 points; the left Achilles reflex recovered (D = S); hypesthesia on the left tibia passed, but sections of hypesthesia along the outer edge of the foot remained in the innervation zone S1 of the root; burning sensation in the left lower limb passed; neurodystrophic syndrome in the left gastrocnemius muscle decreased from 2 to 1 point; pain on the scale of YOUR decreased from 7 to 0 points.

Control examination after 3 months: negative symptoms of tension; muscle strength flexing the left foot - 5 points; knee and Achilles reflexes (D = S); sensitivity in the innervation zone of the left S1 root is normal; neurodystrophic syndrome in the left gastrocnemius muscle - 1 point; pain on the VAS scale after the road - 2 points (4 hours on the road), decreased to 0 points after a preventive session.

According to the control MRI scan of the lumbosacral spine: left-side sequestered LV-SI disc herniation, dorsal size 1.2 cm, base 2.9 cm, spread caudally along the vertebral body SI up to 1.3 cm; at other levels without significant dynamics (Fig. 15, Fig. 16).

Compared with the initial MRI scan, there is a positive trend in the form of regression of the sequestration of the hernia of the disc at the LV-SI level: a decrease in its caudally directed part from 3.1 cm to 1.3 cm.

Example No. 3.

Patient G. 41 years old, locksmith. He was admitted for treatment with a diagnosis of Discogenic radiculopathy L4, L5 roots on the right, often relapsing course, stage of exacerbation, pronounced pain syndrome, iliopsoas and piriformis syndromes on the right.

Complaints on admission: pain in the lower back, right buttock with radiation to the right thigh and lower leg, aggravated by movement, weakness in the muscles of the right leg.

Medical history: for the first time, back pain appeared ~ 15 years ago after exercise. Exacerbations averaged 1 time per year. Gradually, pain in the right lower extremity joined the back pain. The last exacerbation also developed after exercise, lasted with short periods of remission of 1.5 years. During this period, 4 times passed inpatient treatment. The patient was referred for surgical treatment, which he refused.

Received treatment by the claimed method in connection with the lack of effectiveness of conservative therapy and the rejection of surgical treatment.

Neurological status: antalgic heterolateral scoliosis, III stage; positive symptoms of Neri tension, extensor muscles (Laseg and Kernig from an angle of 25 °), piriformis and flexor muscles (Wasserman and Matskevich) of the right lower limb; muscle hypotrophy of the right lower limb; the strength of the hip flexor muscles, extensors of the foot and I finger on the right is reduced to 3 points; the right and left knee reflexes are increased (D ↑ = ↑ S), the right Achilles reflex is reduced (D <S); sensitivity is normal; neurodystrophic syndrome - 1 point; pain according to your scale - 10 points.

According to a neurological study, the patient had extravertebral radicular syndromes (radiculopathy L4, L5 on the right), with muscular-tonic manifestations included in them, anatomically associated with the lumbar and sacral plexuses, as well as vertebral syndrome with analgesic scoliosis.

According to an MRI scan of the lumbosacral spine: left-sided C-shaped scoliosis; dorsal paramedial disc herniation LIV-LV on the right, size 1.3 cm; dorsal hernia of the disc LII-LIII on the left, size 0.5 cm; diffuse dorsal protrusions of the disks LIII-LIV, LV-SI, size 0.4 cm (Fig. 17, Fig. 18).

The treatment was carried out according to the claimed method, which consisted of the actual manual exposure, medication (steroidal and non-steroidal anti-inflammatory drugs, muscle relaxants, B vitamins, venotonics and angioprotectors, cholinesterase inhibitors), wearing a lumbosacral corset and using the bony bone . The neurological principle was the basis for choosing the tactics of manual therapy. The patient revealed extravertebral syndromes anatomically associated with the lumbar and sacral plexuses, in which neutral myofixation of the lower limb is formed (due to tension of the flexor muscles, hip extensors and their synergists) and, accordingly, neutral sanogenizing myofixation of the POP PDS balancing muscle flexion traction and POP extensors, as well as neutral myofixation of GOP and SHOP. The applicant author applied treatment tactics in the neutral position of the spine and lower extremities. MT receptions were performed, starting from the peripheral parts of the body (SHOP and lower limb) and ending in EPP.

This made it possible to treat the neurological manifestations of hernias and protrusions of the lumbar intervertebral discs and to preserve neutral sanogenizing myofixation of damaged PDP POP, which limits their flexion, extension and tilt to the right. In this case, there was no increase in intradiscal pressure in the damaged PDS during MT procedures, and therefore there was no danger of an increase in the size of the hernia or its sequestration. The patient received 2 procedures per week, a total of 15 procedures for 2 months. A good clinical result was achieved: heterolateral antalgic scoliosis decreased from III to I st .; negative symptoms of tension; the strength of the muscles of the hip flexors and extensors of the foot increased to 5 points, and the extensors of the first finger to 4 points; knee and Achilles reflexes are increased (D ↑ = S ↑); sensitivity is normal; neurodystrophic syndrome - 1 point; pain on the scale of YOUR decreased from 10 to 2 points.

Control examination after 5 months: positive dynamics continues - no analgesic scoliosis; negative symptoms of tension; muscle strength of the extensors of the foot and I finger - 5 points; knee and Achilles reflexes are normal (D = S); sensitivity is normal; neurodystrophic syndrome 0 points; pain on the VAS scale - 1 point.

According to the control MRI study of the lumbosacral spine: physiological lordosis is straightened; dorsal right-sided paramedial disc herniation LIV-LV, dorsal size 0.8 cm, base 1.8 cm, vertical size 0.8 cm; at other levels without significant dynamics (Fig.19, Fig.20).

Compared with the initial MRI study, there is a positive dynamics in the form of the absence of analgesic scoliosis, which is confirmed by the restoration of the symmetry of the contours of the iliopsoas muscles on the axial section and regression of the disc herniation at the level of LIV-LV: a decrease in its dorsal size from 1.3 cm to 0, 8 cm

Claims (1)

A method for selecting manual therapy tactics (MT) in the treatment of neurological manifestations of hernias and protrusions of the lumbar intervertebral discs, including studying the direction of blocking in the lumbar spine and choosing MT tactics in the direction of free movement in the lumbar spine, characterized in that they perform a neurological examination of the patient and determine extravertebral syndromes, anatomically associated with the lumbar, sacral, or both of these plexuses, determine the relationship of the direction of myofixation of the lower extremities with the direction of sanogenizing myofixation in damaged vertebral-motor segments of the lumbar spine, as well as with the direction of myofixation of the thoracic and cervical spine, then MT techniques are performed, choosing the position of the spine and lower extremities from: flexion, extensor, neutral depending on extravertebral syndrome anatomically associated with the lumbar and / or sacral plexus, and in the presence of extravertebral syndromes in both lower course MT techniques are performed on both lower extremities, and with extravertebral syndromes anatomically associated with the lumbar plexus, post-activation stretching (PA) mobilization techniques or post-isometric relaxation techniques (PIR), post-reciprocal relaxation (PRR) on the cervical spine, on the lower extremity bending, leading and rotating the femur and on the thoracic and lumbar spine are performed in the flexion position of the spine and lower extremities, with extravertebral syndromes anatomically associated with the sacral plexus, the mobilization technique of PA or relaxation techniques of PIR, PRR on the cervical spine, on the lower extremity of the muscles of the extensor, abducting and rotating the femur outward, the muscles of the extensor and flexor feet and on the thoracic and lumbar spine the position of the spine and lower extremities, with extravertebral syndromes anatomically associated with both the lumbar and sacral plexuses, the mobilization technique of PAR or relaxation The PIR and PRR techniques on the cervical spine, on the lower extremity of the muscles of the flexor and adductors of the thigh, the muscles of the extensor, abducting and outwardly rotating the thigh, the muscles of the extensor and flexor foot and on the thoracic and lumbar spine are performed in a neutral position of the spine and lower extremities, This effect on the lower limb is first performed on muscle groups that are associated with less, and then with more pronounced extravertebral syndromes, the effect of the mobilization technique PAR or relaxation PIR and PRR techniques on the cervical spine are completed by manipulations on both sides, on the lower extremity by pressing myofascial trigger points of the lower limb and lower back, mobilization or manipulations on the sacroiliac joints, manipulations on the thoracic spine, and mobilization on the lumbar spine , at the end of the course of treatment, as the final dose, perform manipulations on healthy vertebral-motor segments of the lumbar spine on both sides, Manipulations on the lumbar spine are performed provided that hernias of the lumbar intervertebral discs are without sequestration and their size is no more than 1 cm in depth.

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